Looking disheveled and wearing shoes without socks, 25-year-old Steven is brought to their family session by his parents, who are deeply worried about his “his failure to launch.” His father begins by describing him as a loner who’s far more interested in computer games than people. Apparently, he hangs around his parents’ house wearing the same T-shirt every day, staying up to the early hours watching his Three Stooges video collection. He’s recently flunked out of college, doesn’t have a single friend, has no plans for the future, and seems to have no sense of urgency or concern about his life. Diagnosed with AD/HD in school, he never really fit in socially as a child—he’s always seemed odd to others, preferring to play alone.
For most of us, trying to get other people to like and care about us is an inherent psychological instinct that’s hardwired. This isn’t the case with people like Steven and others who suffer from Asperger’s syndrome (AS). The world of social expectation has only a remote significance in Steven’s life. This is readily visible in his dress and preference for his own company.
In typical referral cases in which AS is suspected, I meet first with the young adult or adolescent, and then have a session with the parents to assess their perspective and the student’s history. In the individual session, I often raise issues that enable me to assess and motivate the client. In my first individual session with him, I ask Steven about his interests “Trains, and especially train timetables and routes,” he says, suddenly coming to life. He begins asking me what I know about trains and what trains I’ve traveled on in Europe (I’m from England), talking now like an excited young child showing off a new toy.
Despite his animation, I sense that Steven isn’t really interested in me or in having a real conversation. It seems more as though I’m a new opportunity for him to rant about his single passion in life and that I’m just a receptacle for an endless stream of information. As I sit and listen to him, I realize that, as with many AS clients, this is his idea of socializing and most likely the only form of social interaction he enjoys. This kind of monologue provides an excellent representative sample of the larger picture of AS. Language and intelligence are clearly evident as Steven continues his discussion on trains, and yet something fundamental is missing. It’s as if his analytically dominant left brain is running amok; he’s speed-processing digital facts, but is blind to the analogue nuances of social communication.
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.
With my support, he joined a train club not too far from his home. Although this provided him with the beginnings of a motivating social experience rooted in his interest, he needed repeated prompting to attend the meetings. AS clients typically exhibit symptoms of social avoidance and must be encouraged to increase social interactions gradually
Steven is now attending a community college and is making slow but consistent progress toward a degree in computer science. An early focus for us was basic social skills. For example, he was unaware of the social taboo of staring at girls who were attractive to him. We practiced social presentation and nonverbal communication every week. We’d role-play situations and, as homework, I asked him to act out certain scenarios in his room and practice expressing specific emotions. Once we’d achieved a fairly acceptable repertoire, I photographed his best examples and he then placed these on the wall next to his mirror. This helped him practice what each expression felt and looked like on a daily basis.
He’s become more aware of his body language and participates in an acting club on campus, actually preferring this over the train club. As our relationship has developed, he’s begun to understand more clearly several key social concepts, such as the differences between certain types of conversation, which we continue to practice at each session. For example, the chit-chat (informal) mode of conversation was difficult for Steven to understand. He’s had to learn that sometimes conversations have no point or purpose, and that someone doesn’t have to have a correct or better opinion. He’s also grasped the idea that one doesn’t have to express one’s opinion in every situation. The fruits of this work are reflected in Steven’s reports of moments of social success and enjoyment. I plan on seeing him for at least another year, with the goal of gradually spacing our sessions more.
An Asperger’s Marriage
Current data suggest that while most AS adults remain isolated, others can advance into the world of social relations. Two reports from Scandinavia indicate that almost 25 percent of men with AS eventually do marry. In my own practice, I’ve found that males with Asperger’s often make extremely loyal and hard-working spouses. Their single-minded focus appears to filter out the distracting social world, and they often show immense dedication to their families. Given the obvious social difficulties associated with AS, I’m often asked at conferences what attracts neurotypical women to their husbands. Many of these women have told me that, at first, the “oddity” of their husbands appealed to them. One wife once said, “I was sick of men being flaky and uncommitted.” Most believe that their husbands will improve over time, learning to open up and become more relational.
When such couples come in to therapy, it’s almost always at the instigation of the wife, who recognizes that her hopes for change in her spouse are unlikely to be realized. After 10 years of marriage, Cathy had told her husband, Mark, a 35-year-old computer engineer, “Get some therapy or we’re finished.”
Mark arrives for the first session alone. This was intentional, as he’d requested an evaluation for AS. Typically, the spouses of AS husbands secretly hope to have them treated and returned home in some new and improved form. Cathy had recently read up on AS and was convinced it described her husband to a tee. She felt that his being in therapy might be the only way to save their marriage.
On his first visit, Mark mentions the marital issues that had brought him to see me, but also admits to “never being social.” He then pauses, and continues thoughtfully, “Maybe Cathy is onto something.” He explains that Cathy is his only close relationship. As if living out some extreme form of the male stereotype, Mark basically says he has no “use” for relationships or friends. He’s always been a loner, he says, except when he talks to people online on his favorite World War II website. I tell him that, in my view, cyber-communications don’t count as real “relationships.” I’m single-minded on this issue. We have enough research with children to indicate that cyber-relationships and games are no substitute for real interactions and may only increase isolation.
I then ask Mark a question that I’ve found highly useful in diagnosing autism in adults: “Could you give me a brief history of what it was like growing up, what it was like to be Mark? Give me an autobiographical picture, as if you were writing a novel.” He just stares—it’s as if I’d just begun speaking Swahili. I repeat my question, throwing in examples: he can tell me about early family memories, talk about favorite times in school, describe difficult situations. What I then receive is a laundry list of data: where he’d lived as a child, how many years his family had spent there, what his father did, a countdown of his relatives, the names of schools he’d attended, what he’d studied, what he’d majored in. There’s virtually nothing about people, relationships, personal experiences, or emotional responses to events.
When I turn to his relationship with Cathy, Mark states that things haven’t been too good lately. “I just don’t understand what she wants and what she expects me to do,” he says. It’s clear that Mark is honestly confused and desperate about the situation. He’d thought that they were both ready to have children, and now she’s indicated that she doesn’t feel that way anymore.
I ask for an example of a typical area of conflict and he offers the ongoing fight about seeing friends. “Even if I do go out, she says I sit there and don’t say anything, looking angry.” Apparently Mark just doesn’t pick up on the necessary social niceties of “meaningless” or non-instrumental conversation. He cares about Cathy, but is at a loss when it comes to imagining her needs or desires.
When I later meet with both Mark and Cathy, she tells me, “I think he cares about me in some way, but I’m not even sure of that lately.” She shares that he appears to have no interest in socializing and describes their relationship as mostly “functional.” Mark admits that he’s persistently confused by her behavior and has learned to leave well enough alone. For an individual with AS, this is a perfectly viable, but eventually destructive, option. The computer room and his obsessive interests are waiting for him at any time, but he doesn’t comprehend the possible relational ramifications of this temporary escape.
In couples treatment when one of them has AS, I initially explore and highlight the different operating systems or learning styles of the partners. This serves to normalize their struggle and lessens the tendency to blame the identified patient. I often use Jung’s concept of The Thinking Introvert to encapsulate many features of adults with AS. I suggest that couples view Asperger’s syndrome as an extreme variation of the thinking-introvert type, describing ways that this can cause conflicts with others who don’t share this learning/person-ality style. My emphasis in the beginning is to work with partners to find ways to become aware of their differences and experiment with new ways of relating.
While couples work is part of my approach with Mark and Cathy, I’m concerned that too much emphasis on this could cause him to become overwhelmed and quit. I’ve found working with AS clients that it’s vitally important to motivate and encourage them continually. Far more than his wife, Mark needs help learning concrete strategies to expand his capacity for relating to people. If they remain together, their marriage will have to adopt a new conversation, one that recognizes and accepts the reality of each one’s inherent gifts and limitations.
Obsessing—a common feature of AS—often leads Mark to disconnect from Cathy and become totally absorbed in one of his habitual anxieties or fixations. In one conjoint session, she complains, “He’ll suddenly change the subject or just get up, and then wonders why I’m angry.” In both couples sessions and individual sessions with Mark, we take frequent steps back and attempt to understand how these breakdowns in relating occur, how to recognize them, and how to manage them. We role-play social situations again and again, and I ask him repeatedly to look at my facial expression. I give him software on social expressions to use at home. I regularly inform Cathy about the strategies I’m using and give her recommendations about how to alert Mark in critical moments. All of this work is reinforced in our couples sessions.
As both a duo and a threesome, we move repeatedly back and forth between enhanced social awareness and skill practice. Highlighting the different perspectives each brings to their marriage, Cathy is crowned the “relational expert,” responsible for setting up procedures for social problem-management. In contrast, Mark is made the family’s official financial and computer consultant. I keep encouraging them to explore their learning styles and individual ways of being in the world.
Mark and Cathy are now moving forward, and I see them every two weeks. I expect they’ll continue to need counseling periodically in the years to come.
Is It Love?
I’m often asked about the kind of love adults with AS experience toward their partners and family members, because it doesn’t appear to be grounded in the outward expression of warmth and caring that most of us strive for. Parents of children with AS often confide to me that they’re unsure whether their children really feel loved, or even like a part of the family. In trying to explain the way people with AS express love, I often remember one of my early trainers who’d lived through the World War II blitz over London, when the city was ablaze every night as bombers unleashed their fury. I asked him what it was like to see this daily carnage and terror as a teenager. He calmly explained that he remembered often looking up at the bombers flying overhead and thinking “How very strange that people would do such a thing; it’s really quite absurd.”
This man cared deeply about his country and his people, yet expressed this reaction in a detached, unemotional manner. Did he care any less than the man or woman who screams hysterically about such atrocities?
I’ve always been taken by the idea that there are conventional and unconventional ways of expressing love in any given situation. As relational beings, we have to be clear about what kind of expression we need or desire. Like most high-functioning men with AS, Mark understood the core of love to be loyalty, dependability, and hard work. Cathy will need to come to terms with the possibility that this may not be enough for her. The decision about whether Mark ultimately offers her the kind of affection and growth she’s looking for in a relationship can only be made by her.
Richard Howlin, PhD, is a clinical developmental psychologist and director of the Chelsea Center for Asperger Syndrome in Chelsea, Michigan.