The Missing Piece - Page 2

Steven is obviously ready to go on all day talking trains. I politely interrupt and begin asking about other issues, including his recent difficulties at college. He tells me the basic details of his situation in a monotone voice, leaving me with little understanding of what really happened, much less how he feels about it. He says college was "not good" and not suited for him. He states that he thought college would be different from high school, but he found it to be the same. On further inquiry, he states that college was about lots of people doing the "same bullshit" as in high school. At this point, I'm driving our conversation and Steven looks uncomfortable and reluctant to reflect.

As I probe deeper, I find myself asking the questions and feeding him the answers: "So you felt overwhelmed," to which he robotically responds, "Yes, I felt overwhelmed." He's fully capable of expressive language and isn't short on vocabulary, but there seems to be nothing behind the almost rote repetition of the words—no interior sense of self or ability to take me up on my attempts to connect. He doesn't appear to have either the ability or the desire to reflect on himself or his circumstances.

He knows I'm there and that I expect something from him, so he tries to throw together a response that might fit the situation. As I soldier on, making my best effort to empathically relate to him, he abruptly interrupts to tell me that my coffee cup is too close to the computer monitor. I move it and he's silent again, vacantly staring out, avoiding my gaze. From experience, I imagine that the only thing he'll recall from our meeting is that I frequently used to travel on the Flying Scotsman from London to Glasgow. After our session, I'm left with the memory of having made a diagnosis, but almost no contact with the person behind the label.

Adults with AS often behave as if they were confused actors walking onto a stage and being the only ones who don't know the lines or the plot. Worse still, their ability to fake it—to just pick up the emotional tenor of others—is severely limited by their concrete, inflexible thinking style. People with AS aren't able to shift their attention easily or adapt to changing circumstances. Unexpected departures from routine can throw them into complete catatonia.

I eventually begin my treatment with Steven by discussing the strengths and challenges of AS, describing it as an extreme learning style. I offer some basic information about the nature of Asperger's syndrome, including demographic studies that suggest an incidence of at least 1 in 200 people, with 90 percent of these being males. In lay language, I explain that the condition appears to stem from a lack of neural integration, rather than from discrete neurological impairments. As a result, children with Asperger's typically have normal language and intelligence. In fact, problems often become evident only later in their development, and many individuals reach adulthood without diagnosis.

I also meet separately with Steven's anxious and exhausted parents and follow these separate sessions with a conjoint family summing-up session. When I explain that Asperger's is a neurobiological condition that isn't a result of poor parenting, his parents are profoundly relieved to hear that the cause of their struggle over all these years has a name and that their concerns and exhaustion are shared by many parents in their situation. Then tears of relief and sadness start to flow. These moments with parents are among my most touching experiences as a psychologist, since I identify with the emotional toll of raising a socially confused and often rejected child.

Asperger's syndrome places the therapist face to face with the separate realities of social and analytic intelligence: two fundamentally different ways of understanding the world. Most of us have some level of integration of both domains, which allows for a more efficient and flexible response to changing circumstances. In AS there's usually an extremely dominant, analytic, left- hemispheric bias, which leads to seeing the world as isolated elements without context. Adults with AS feel they need every piece of information before being able to make any decision and are unable to discriminate between the essential and the nonessential. One of my initial goals in therapy is to provide clients with an awareness of this bigger picture, helping them realize the role their brain plays in their everyday practical and social understanding. With both the client and the family, I go over in detail the problems related to empathy, communication, and executive skills typically experienced by clients with Asperger's.

Treating the Individual

Therapy with AS is a step-by-step process of skill training, life planning, and helping clients integrate their unusual and obsessive talents into a productive life. With Steven, our time was balanced between working on specific behavioral goals (i.e., improving his sleep schedule) and the more complex process of social skill training and enhancing communication awareness.

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