Bromfield on Therapy with Children and Adolescents with Asperger Syndrome

Asperger’s as a diagnosis can appear to preclude the existence of fulfilling human relationships for the young people concerned. But Bromfield’s “relationship-based therapy” for his young clients shows that they have the same human needs for relationship as others, they just have trouble expressing them in socially proficient ways.

Rating: 4.5

Doing Therapy with Children and Adolescents with Asperger Syndrome

By , 2010. ISBN 9780470540251. John Wiley & Sons. 217 pages.

“I speak of the trauma that [their] neurological differences bring about; the misunderstanding, overstimulation, neglect, social isolation, teasing, and so on that can pervade the days of a child with Asperger’s. Not only will I not do any of these things to you, I wish to convey to the child in the opening phases of therapy, but I will also try to undo them, or at least provide some of what has been wrong or missing.” (p. 22)

Richard Bromfield, a practising psychologist from Havard Medical School, is known for his insightful, practical and accessible books on therapy with young people. (See my earlier review: “Bromfield on Teens in Therapy”.)

While explicitly informed by research, the strength of this book is the sense he gives the reader of participating, of being right inside these challenging yet tremendously productive therapy relationships along with himself as therapist and his young clients.

Bromfield writes, “I’ve found that children with Asperger’s seem to enjoy the company of therapists with not just an honest but a solid, down-to-earth presence. These children are not ones for psychobabble or tentative hypothesizing.”

The congruence between what is, one senses, Bromfield’s own personal style; his work with these particular children with their “extra” needs for authenticity, honesty and groundedness; and his style of writing is striking and adds to the power of the book. It has already, if you like, been through the acid test of scrutiny by children who have an uncanny instinct/skill for reading through insincerity and recognising and appreciating those who are sincere and worthy of trust.

Asperger’s is a diagnosis which can appear to preclude the existence of fulfilling human relationships for the young people concerned. They are said to be to varying degrees incapable of functioning socially, and are sometimes seen as not even having such a desire or need.

Bromfield engages in “relationship-based therapy” for his young clients and discovers that they have the same human needs for relationship as others, they just have trouble expressing them in socially proficient ways. Bromfield comes across as warm, empathic, humorous and creative in his work, willing to spend an hour a week for months reciting alternate lines of a nursery rhyme, or devising a vocabulary of bear sounds for emotions (p. 65). He is also willing to respect the need for aloneness, staying with the child respectfully but allowing them to remain in their own private and impenetrable space when they need to. These qualities are clearly appreciated by his clients, whether they express it by kissing objects which belong to him, by rushing to sessions in which they appear not to participate, or in more conventional ways.

Research findings tend to conclude that people with Asperger’s lack a “capacity for fantasy, imagination, and symbolic play” and have “an inability to read or understand what [went] on in other people’s minds” (p. 160); from these conclusions, a consensus has been reached that talk therapy and play therapy are therefore doomed to failure. Bromfield’s response is: “though the child’s relative hardship in expressing herself emotionally and symbolically has been viewed as a reason not to attempt the play and talk of therapy, my view is that the deficit is precisely the reason such intervening works and is called for.” (p. 164)

One by one, Bromfield takes neurological features which have been used as arguments against the use of therapy with people with Asperger’s, and shows how they are relative and to some extent flexible capacities, which may grow. Most importantly, the desires behind the difficulties are “non-Asperger’s desires” — desires for the basic gratifications of communication and mutual understanding. As Bromfield points out, were these needs not present, life for the child with Asperger’s would not be so hard, they would not be so vulnerable, they would not need to try. On top of the efforts to understand and be a part of things, along with the strain and inevitable misunderstandings, stress and overwhelmedness, there is also the stigma and prejudice which others can hold against those who are “different”. These too are felt by the children; they hurt.

So how does Bromfield suggest a therapist may help develop the capacities and honour the needs of the child? For example, he values the imaginative elements of play which might look different from the pretend play of the client’s peers, modifies traditional forms of talk and play therapies in order for the children to be able to enjoy and develop the capacities they already have, then watches their capacities grow far beyond expectations. And in the area of empathy — another trial for the child with Asperger’s — gains can be demonstrated not by any kind of training, as if empathy were a skill, but by the therapist repeatedly failing in his own empathic attempts, and the acts of repairing that, thereby showing care, and building up a real relationship.

The invention, for example, of new languages with which to navigate what appears to be an alien planet might capture the experience of a child with Asperger’s in High School, and also the experience of the therapist with the child. Thus the weirdest flights of fancy are grounded in the direct, present experience of therapist and client, both of great alienation, and of curiosity and desire to communicate.

Bromfield gives examples in which, for example, the concrete language for which Aspeerger’s children are well known, becomes a series of wild and funny metaphors (p. 75), a secret source of hilarity shared with the therapist, whose reciprocal building up of the language serves a serious purpose, teaching the child skills which will help lessen their anxiety outside the therapy room. (Not to mention the fact that Asperger’s as a diagnosis is supposed to pretty much rule out a sense of humour).

The case histories show how extraordinarily long and difficult the process of helping a child with Asperger’s can be, but also how successful it can be — with children whose future was predicted by experts to be a lifetime in care growing up to take responsible jobs and living fulfilled lives on their own terms. The case histories are detailed and do not gloss over the difficulties, or sport a triumphal tone. A short chapter at the end of the book addresses parents directly, and throughout the book the difficulties they face and the resources they display are explicitly addressed.

Bromfield recommends a flexible approach to therapy and uses whatever might work, taking cognitive behavioural techniques for example and using them with a great deal of success with some clients, teaching relaxation techniques, and remaining open to the role of medication where helpful.

As a therapist with a different client base, I found inspiration for my own work. The heart of therapy — keeping empathic contact however hard it might be (listening to extraordinarily specialised and detailed monologues for instance), treating the client with the utmost respect and using a wide knowledge base and intuitive sense of what might practically, with this person, be of help — is beautifully expressed in the book.

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