Emotion-Focused Therapy for Autism Spectrum Disorder: A Case Conceptualization Model for Trauma-Related Experiences

EFT draws upon a Task Analytical methodology to study psychotherapeutic change within a discovery and validation phase (Greenberg 2007; Pascual-Leone et al. 2009). The discovery-oriented phase of task analysis involves the construction of a specific model of client change process and a method of measuring its components. A rational model is constructed and acts as a record against which future observations can be checked (Greenberg 2007). This ASD case conceptualization (Robinson 2017) has been guided by the framework initially developed on research on emotional transformation in experiential treatment of depression (Pascual-Leone and Greenberg 2007) and specifically for Generalized Anxiety Disorder (Timulak and Pascual-Leone 2014). To the best of my knowledge this is the first presentation of a rational-empirical model of working through trauma related experiences for ASD (see Fig. 2). This rational model acts as a hypothesis for testing in subsequent trials (the author is currently leading a program of research for EFT-AS).

The case conceptualization model (see Fig. 2) presents a clinical strategy and actions of a therapist working with clients with autistic process. The strategy consists of several aspects within three phases leading to emotion transformation. The therapist uses this case conceptualization framework to inform the dynamics of the client’s distress (see phase 1 Fig. 2) using this to orient identification of triggers and self-treatment, overcoming avoidance and focusing on the underlying core painful emotions. Following this, the therapist supports the client to articulate the unmet need (see phase 2 Fig. 2). For the client with autistic process this can involve access to distanced trauma related experiences, evoking and activation of emotions associated with the event and experiential processing of these emotions.

Once the client is able to access their core pain and to articulate the associated unmet need, the next step for the therapist is to facilitate emerging adaptive emotions (see phase 3 Fig. 2), such as compassionate responses to self. In conjunction with an empathic relational stance, as EFT-AS is a group therapy, the therapist has the potential to facilitate compassionate responses from other group members. In addition to compassion, assertive and protective anger is generated in well proceeding EFT cases (Timulak and Pascual-Leone 2014). In EFT, it is seen as an important step in the transformation of emotions that the client feels the anger in the moment.

The therapist seeks to facilitate both self-compassion and assertive, protective anger. This is achieved through enactment tasks, such as an imaginary dialogue of a situation in which the client can speak their truth to a significant other (e.g. a lost parent) or express their anger to a harmful other (e.g. abusive bully). The therapist can use IPR to scaffold barriers to the imagination required when working with multiplicity or parts of self through two-chair enactment tasks. Specifically, in EFT-AS the visual image of self can be on screen and the client can speak to their fragile or broken younger self from the position of stronger adult self. Research indicates that once self-compassion and protective anger have been achieved and expressed, a grieving process can begin (Pascual-Leone and Greenberg 2007; McNally et al. 2014) as shown in the final phase of the case conceptualization model (see phase 3 Fig. 2). Finally, these emerging adaptive emotions facilitate mentalization of self (theory of own mind) and other (theory of your mind) that strengthens intrapersonal and interpersonal agency. This case conceptualization is illustrated in the following case example.

The therapist is listening for client triggers that are current, interpersonal situations that trigger underlying painful emotions, such as isolation or rejection. A problematic relational problem that people with autistic process report is having their emotions misunderstood by others. Therapists are looking for emotion markers to identify and change negative interaction cycles. This can be described as a form of misempathy (emotional misunderstanding). These markers can occur as interpersonal ruptures in the session between group members or through client dialogue of past negative interpersonal experiences. Misempathy is a trigger within EFT-AS and is often reported by most clients. Martin referred to a number of historical as well as current triggers that brought him distress. Specifically, the therapist identifies emotion misunderstanding dialogue that indicates a client believes their emotional intentions have been misunderstood by others. For example,

It is proposed that triggers of problematic emotional processing in ASD are current situations that trigger underlying painful emotions that resemble interpersonal ruptures that have occurred throughout childhood, adolescence and persist into adulthood. These are chronic recurring social-emotional patterns of failed interactions that led to developmentally significant emotional injuries (see Fig. 1). These originate from core ASD difficulties of social-emotional processing through self-understanding, such as emotion regulation, self-reflection or theory of own mind and other-understanding, such as empathic attunement and mentalization or theory of mind. The triggers are actions or perceived actions of significant others (i.e. peers) such as rejection (i.e., exclusion, invalidation and humiliation). Emotional schematic processing builds on memories of unsuccessful processing of difficult situations, leading to chronic maladaptive emotional experiences (Greenberg 2011). Observing current triggers bringing painful emotional experiences reported by clients with autistic process, in clinical practice, it appears that many of these triggers resemble the ones reported by clients with depression and social anxiety. In fact, clients with autistic process have significantly higher rates of comorbid anxiety and depression then the typical population. They include developmentally delayed social communication and interaction skills, followed by repeated and chronic, failures to socially interact and a perception of repeated and chronic, hurtful actions usually by peers, such as rejection, exclusion and stigmatization. Furthermore, these tend to be associated with failures by adults to prevent such treatment.

Potential threats (triggers) are all pervasive for a person who has a desire to relate to others but is in a state of interpersonal confusion and constant fear of rejection. Furthermore, efforts to avoid triggers or cope with them do not avoid the emotional pain but on the most part, lead to exhausting longing with persistent sense of inability and fearful apprehension. Thus, clients with autistic process present with a sense of not belonging or fitting into the world, of hopelessness, helplessness, desperation and annoyance at self for social inadequacies and fear of interpersonal encounters. These emotions are secondary to more primary unbearable and unprocessed core painful feelings. They are typified by low differentiation of various feelings and an overall global sense of being distressed.

The therapist should be attuned to key repeating triggers of client problematic process that point to the underlying determinants of their difficulties. An example of an autistic process (AP) marker is identifiable by the client’s expression relating to a lack of self-agency within interpersonal relationships. This can be seen when Martin shares his rationale for moving to University so he can develop social relationships. Martin spoke of how he left his job to go to University because he could not get a social life after leaving school. He wanted friends and thought by going to University this would increase his chances of succeeding at this. For example,

Martin: I found that, you’re supposed to have a balance of a social life and work life. I couldn’t get that balance. Well, I couldn’t get any social thing out of it really, so I ended up not studying anything. […]

Martin: When I was, when I worked straight from school it was the same, that’s probably why I left to go to University I was hoping for something to change but it didn’t happen. I was hoping for change I thought this would be a chance it just got worse because my expectations were too high.

Through observation, clients with autistic process attempted to deal with distress or potential distress by controlling their own actions (withdrawal), others behavior (dominant controlling actions) or their environment (see Fig. 1). They engage in repetitive thinking by punishing themselves, or being negative towards the self whilst preparing for the distress of rejection. In the context of problematic triggers (e.g., failed social interactions with negative judgment by others) the clients could be preparing the self (e.g., its never going to happen) by beating themselves up or preventively judging the self (e.g., I’m not capable) and in this way trying to improve their own coping or at least prepare themselves for the pain of rejection. Typically, they might make the self responsible for any potential negative interaction (e.g., I can’t talk to people, I can’t say things the right way). There can also be genuine dislike and non-acceptance of self (e.g., I’m weird, I’m not normal). In accordance with Timulak and Pascual-Leone (2014) it is hypothesized that negative self-judgment can be an introjected criticism from others. Further, it is hypothesized, that for clients with autistic process this negative self-judgment manifests as a fragile sense of self as a consequence of concrete experiences of habitual failed interpersonal encounters. These are based on their social interaction differences that occur in childhood with TD peers and significant adults that persist into adolescence and adulthood.

The case conceptualization begins at phase 1 (see Fig. 2) with approaching emotion and exploring distress as it involves deepening the clients experience and facilitating self-awareness of triggers and differentiating global distress. The therapist identifies autistic process (AP) markers, selects and edits these for video IPR and plays these in the following recall session. These IPR clips have multiple markers for multiple clients and they are offered to the group. In session, the therapist plays IPR selected moments of negative self-treatment, fragile sense of self or the self-critic and uses these to deepen the clients self-experience through an empathic relational stance and for setting up intrapersonal and interpersonal therapeutic work. For example,

[part of an IPR edited clip]

Therapist: How did that make you feel? That you had gone to University, you’d wanted friends and it didn’t seem to happen?Martin: I felt that there was something not right about me. Something wrong. I just didn’t think there was anything to do and that there was no point in trying anymore, so I became more isolated and stuck in my flat on my own.

Creating narratives about oneself requires internal coherence (Pascual-Leone 1990) a particular challenge for people with autistic process as they have autobiographical memory difficulties characterized by reduced specificity, less detailed self-narratives with lower coherence (McDonnell et al. 2017). Further, there is currently limited research to the extent that people with autistic process experience and emotionally process coherent narratives relating to trauma. These particular issues with trauma retelling mean that trauma memories may be distanced or may not be identified as trauma. Therefore, trauma retelling usually begins with the current trigger of avoidance of people, of not getting it right or of being misunderstood by others.

The therapist uses this presenting issue or undifferentiated global sense of helplessness and selects this for video IPR to play in the following session. This is used as a process-guiding task within trauma retelling to expand and specify autobiographical memory recall, to evoke emotion activation usually for overregulated emotion states, scaffold the imagined two-chair enactment task by showing the fragile self part visually and to deepen experiential processing.

During the session there was a slow recall of the memory as Martin processed the distanced experience with a lack of self-agency and resigned despair. For example,

In EFT, the core pain is the underlying primary painful emotional response to the triggering situations or perceived trigger (Timulak and Pascual-Leone 2014). The term core pain is used as it indicates to the therapist that these painful emotions should be the focus in therapy. At the core of the ASD dynamic, there are emotion schemes centered on painful emotions that are pervasive, overwhelming and painful that in part are primary maladaptive emotions (Greenberg 2011) as they do not serve any adaptive action and thus the client wants to avoid them. However, autism is often referred to as a hidden disability with associated limited capacity to read the emotions and intentions of others, this means they can be vulnerable to victimization from others. Therefore, in part there is some aspect of ‘logical self-protection’, but when these are coupled with restricted repetitive thinking can become entrenched thought patterns. Hence, why a psycho-education approach to teach social skills is often the preferred course of treatment for people with ASD. From observations in clinical practice, this approach does not treat the underlying core pain and emotional injuries.

The case conceptualization moves to the second phase, by working through primary maladaptive emotions (see Fig. 2). It is hypothesized that for ASD emotions are shame-based (e.g., I am broken, defective), loneliness/sadness based (e.g., I feel alone, I’ll always be alone), and fear/terror-based (e.g., I am frightened of you, you’ll reject, attack or hurt me). Once the trauma and chronic associated feelings have been accessed by the client with autistic process, the underlying core painful feelings centers on a profound sense of loneliness, shame and traumatic fear.

Varying degrees of resolution involve clients reaching their core pain and using it to better understand self and others. The primary goal of the therapy is to process the presenting maladaptive emotions that diminish the self, such as self-loathing and passive, hopeless despair. Specifically, EFT-AS promotes in-session experiencing of emotion with the goal of fostering, with the supportive guidance of the therapist, an acceptance of experienced emotion, a capacity and proficiency in regulating emotion and in self-soothing, and a transformation of destructive or ‘maladaptive’ emotions to more healthy alternatives. For example,

In recall, the therapist deepens the experience to move towards the core pain.

In EFT, research indicates that for depression, trauma and anxiety certain types of needs are associated with certain clusters of primary and painful emotions (Timulak and Pascual-Leone 2014). These experienced core pain indicates that the client’s needs are not fully met (Greenberg 2011). The needs corresponding with shame-based emotions include, the need to be seen, included and acknowledged. The needs corresponding with loneliness/sadness-based emotions include, the need to be connected, cared for, be liked/loved. The needs corresponding with primary terror/fear-based emotions include, the need for safety and protection, control and self-agency.

This begins the process of discovering Martin’s core pain and this stems from his feelings of desire for, but never having any friend and relationship, to feelings of deep sadness through loneliness. Once we reach this core pain this is further explored to discover additional associated core pain, with the aim of facilitating emotion transformation in the final phase of therapy (see phase 3 Fig. 2).

One of the core principals of EFT is you have to arrive at an emotion (core emotion) and change this with an emotion (Pascual-Leone and Greenberg 2007). Therefore the key to successful task resolution is emotion transformation. In Martin’s case conceptualization he experienced trauma as a result of chronic bullying, which was evoked as a distanced vulnerability during the second phase of therapy. This led to experiencing the anger in session that moved towards assertive protective anger for self. For example,

Martin: The annoying thing was that the adults were calling me the name as well, so the anger that that generates is still there... […]

In EFT, clients engage with enactment tasks which involve dialogue with different parts of self or imagined significant others, such as a parent or an abusive other. These tasks, as well as an empathic relational stance, are the main means of accessing emotions to make them available for exploration and transformation. Thus, adequate processing of sadness at loss and anger at violation often form the adaptive core of the treatment of both depression and anxiety (Greenberg 2011). This can present a challenge for clients with autistic process who have cognitive empathy difficulties, such as self-awareness or theory of own mind (Williams 2010) and mentalization of others mind (Baron-Cohen 1997) as well as restricted repetitive thinking. However, an enactment task (unfinished business) was explained to Martin and he was able to respond to his own core pain of sadness at his feeling of abandonment by his dead father. For example,

In EFT-AS an important component appears to be the potential for interpersonal compassion from others within the group. The benefits of this are two-fold, for one, a hurt fragile self can be soothed if another group member offers compassion and second, affective empathy can be evoked by an observing client and then used to explore their emotional response. For many autistic people, interaction with other autistic people is preferable to interacting with neurotypical people (Sinclair 2010). Further, Sinclair asserts that for him and others there is a growing realization how much autistic people have to offer each other through peer support. Most people with autistic process have early childhood experiences of being with TD peers and often it is only in adulthood that they may come to interact with other people with autistic process. It is proposed that having autistic group members offers opportunity for shared autistic attunement and as such there is the potential for an ‘autistic coach’. For example,

Further, having EFT-AS in a small group format provides opportunities for evoking compassion responses. These can act as an addition to self-soothing. The therapist can scaffold this potential compassion reciprocity. For example,