The Key to Diagnosing Autism Spectrum Disorder in Adults: Theory of Mind

Introduction

Autism spectrum disorder (ASD) is a neurodevelopmental disorder. It poses life altering challenges, both for those who live on the spectrum((I never say somebody “has autism” or is “autistic.” Instead, I talk about “living on the spectrum” or “living with autism.”)) and for those who care about them.
If you provide psychotherapy to adults, you will discover patients who live on spectrum.
Often patients who do not live on the spectrum((Sometimes people not on the spectrum are referred to as “neurotypical.”)) have spouses, children, parents, friends, work supervisors and others on the spectrum.
It is important that all providers of psychotherapy for adults be competent in diagnosing ASD in adults for two reasons:
- Your patients who live on the spectrum can learn about their assets, growth edges, and limitations so as to better manage their social relationships, social communications, and their emotional reactions.
- Patients not on the spectrum can exercise empathic concern for those people on the spectrum.((Of course, ethical psychotherapists do not diagnose people who are not their patients and, therefore, have not given informed consent to be diagnosed. A delicate line exists between helping our patients understand others’ situations and not enabling our patients to wield a diagnosis of autism like a light saber.))
Diagnosing ASD in adults is straightforward((Please note that this post is about adults. Please leave the diagnosing ASD in children and younger adolescents to specialists in psychology (e.g. child psychologists, school psychologists, or some neuropsychologists), pediatricians, or child neurologists.)) for any licensed psychotherapists who has learned the basics about ASD.
Because this post is not a comprehensive overview of ASD, please pay close attention to the ASD diagnostic criteria and the accompanying discussion in the DSM-5™ (American Psychiatric Association, 2013).

The problem

As useful as the DSM-5 overview of ASD is, it does not explicitly acknowledge theory of mind (ToM) deficit.
Theory of mind, or more accurately the lack of theory of mind, is implicit in ASD; the disorder cannot exist except in the absence of theory of mind.

Theory of Mind

ToM has two equal parts:

1. The awareness of the mental states of others, specifically, what other people believe (cognitions), what other people feel (emotions), and what other people want (intentions).
2. The awareness that the mental states of others can be different from one’s own mental states.

Examples of theory of mind deficits

Deeply held belief in the accuracy of one’s own assessments of others’ mental states. Profound resistance to altering one’s own beliefs in spite of contrary objective evidence.
Personal identity firmly tied to one’s own beliefs no matter how illogical in the larger context.
Unconsciously ascribing one’s own mental states, especially negative ones, to others. Often quick to see hostility in others where none exists.
Narrow framework of subjective reality divorced from logic and science.

Diagnostic criteria

If you are having difficulty in assessing an adult for ASD, here are my suggested changes to the DSM-5 criteria for ASD. I have divided criterion “A” into two parts. The quoted passages below are directly from the DSM-5. I have much respect for the authors of the DSM-5. Their scholarship and clinical experience are obvious, and the DSM-5 remains the single best description of ASD. My justification for adding ToM as a criterion is that ToM demystifies diagnosing ASD in adults.

Persistent deficits in theory of mind that go back to age four to six years and continue to the present. Note that in normal development ToM skills first appear from four to six years of age.
“Persistent deficits in social communication….”
“Persistent deficits in social interaction….”
“Restricted, repetitive patterns of behavior, interests, and activities….”
Some evidence that the symptoms go back to early developmental history.
“Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.”

Differential diagnosis of autism spectrum disorder

Unresolved complex trauma sometimes appears as ASD. (Note that children with ASD often become targets for childhood maltreatment, but that is another part of the ASD narrative.)
ToM deficits can be present in other disorders, especially schizophrenia.
Attention-deficit/hyperactivity disorder (ADHD) appears similar to ASD, but closer analysis of patients displaying only ADHD soon reveals a functioning ToM and, therefore, no ASD.
The DSM-5 lists the following for consideration of differential diagnosis: Rett syndrome, selective mutism, language and communication disorders, intellectual disability, stereotypic movement disorder, attention-deficit/hyperactivity disorder, and schizophrenia.

Associated Signs and Symptoms

The following list can make clinicians aware of the possibility of ASD in an adult. These items are only suggestive, the proverbial “where there is smoke, there may be fire.” A conclusive diagnosis of ASD for an adult must rely on the DSM-5 criteria.

Rigid, naïve expectations of others, especially authority figures, sales people, professionals, tradespeople, and family members, even children.
Frequent aversion to everyday visual, tactile, auditory, olfactory, and gustatory stimuli.
Intense dislike of novel stimuli: Even a change of the packaging in a breakfast cereal.
Preoccupational interests: Those that are either highly unusual in themselves or unusual in the resources devoted to the interests.
Employment difficulties: Successful employment is more about getting along with others than the core knowledge, skills, and abilities of a job. The modern workplace is about teams – the lone craftsperson is largely a thing of the past.
Not waiting to be invited into activities in new settings, e.g. school recess or new workplace.
Obsessive-compulsive issues: Valuing routine and sameness.
Savant abilities.
Substituting numerical values for human values. Often “funny about money.”
Troubled intimate relationships.
Transactional style in all relationships.
One sibling singled out for maltreatment by parents.
Children singled out by adults or peers for maltreatment in K-12.
Conflict with authority (Please see #1 on this list).

Please note that I did not include eye contact on this list. Some patients without ASD never give me sustained eye contact, and some patients with ASD stare at my eyes for entire therapy sessions. The lack of eye contact is relevant in infants and children, but not adults.

The Utility or Inutility of Diagnosis

ASD especially in men is common for unhappily married couples.
Some adults find the diagnosis of ASD comforting as ways of explaining their social difficulties and illuminating their growth edges.

Evolutionary Psychology and Autism

Hypothesis: People with ASD have been necessary for the survival of their communities because (1) different world views and (2) conflicts with authority provide communities with alternatives to groupthink.

Internet diagnosis

Lay people often believe that the internet gives them the ability to diagnose ASD.
But, lay people are often more interested in weaponizing the diagnosis,
Or they neglect the DSM-5 language: “(C)linically significant impairment in social, occupational, or other important areas of current functioning.”
Accurate or not, diagnosis must be left to professionals who have obtained informed consent of individuals being evaluated.

Levels of Severity

The deficits in social communication and the deficits resulting from repetitive behaviors vary from
- Requiring support
- Requiring substantial support
- Requiring very substantial support
Usually if ASD is not diagnosed until adulthood, the severity level is most often “requiring support.” The more serious levels of severity would have been noticed before adulthood.
Often adults who live on the spectrum manage to have careers which range from decent to spectacular, but their personal lives are problematic.
Some adults meet some but not all of the ASD criteria. Although they do not live on the spectrum, they are socially marginalized and, hence, lonely.

Selected bibliography

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington DC: Author.
American Psychological Association (2017). Diagnosing and Managing Autism Spectrum Disorder. https://www.apa.org/topics/autism-spectrum-disorder/diagnosing
Badcock, C. (2009). The Imprinted Brain. Philadelphia PA: Jessica Kingsley.
Doherty, M.J. (2009). Theory of Mind. New York NY: Psychology Press.
Finch D. C. (2012). The Journal of Best Practices: A Memoir of Marriage, Asperger Syndrome, and One Man’s Quest to Be a Better Husband. New York NY: Scribner.
Wilkinson, L. A. (Ed.). (2014). Autism Spectrum Disorder in Children and Adolescents. Washington DC: American Psychological Association.

Endnotes

For the past 10 years I had been mulling over the question: What is the quintessential symptom of autism spectrum disorder?
I had repeatedly turned to ToM deficit, but that answer never was satisfactory.
Then I realized that ToM deficit is not the quintessential symptom but rather a necessary but not sufficient condition.
I hope that by making ToM deficit explicit, clinicians will be less cowed by the volume of material about diagnosing ASD in adults.
And, perhaps more importantly helping people on the spectrum acknowledge their growth edges and to find workarounds to reach higher levels of social functioning.

Thank you,

Dr. Michael DeCaria

(The featured photo was taken by the author in Salt Lake City on 2 February 2021, Groundhog Day in the USA and Canada.)

Psychotherapy and Psychology

A 21st Century Take on Grief

Introduction

10th East-2

A few years ago I attended a paradigm altering workshop on grief presented by Ligia Houben. Among her many credentials, Houben is a life transitions consultant and coach in Miami, Florida. Here is a link to her website: https://ligiahouben.com. She has revolutionized Elisabeth Kübler-Ross’s seminal work, On Death and Dying. You know: The five stages of grief. In my opinion, Houben is as significant now as Kübler-Ross was then in understanding grief and loss.

You can find out more about Houben’s model of grief and loss and recovery from her book: Houben, L. M. (2017). Transforming Grief and Loss Workbook. PESI Publishing & Media: Eau Claire WI. I highly recommend the book; it is available on Amazon. Houben has broken down her model into 11 principles. With her permission I am quoting them exactly for you. Her books and her website will illuminate these principles for you.

The 11 Principles of Transformation®

Accept Your Loss
Live Your Grief
Go Deeper into the Spiritual Dimension
Express Your Feelings
Share with Others
Take Care of Yourself
Use Rituals
Live the Present
Modify Your Thoughts
Rebuild Your World
Visualize the Life You Want

Two of Houben’s Significant Advances

The principles are not stages. All are important to be worked on more or less simultaneously.
Accepting is the first principle and part of the journey – not only a destination.

I hope you will look at Ligia Houben’s work to assist in managing loss and transition.

Thank you for following my blog!

Dr. Michael

(The photo is of a wild pyracantha bush in my neighborhood. The time was late February 2020, a winter day with spring sensible in the air. I like the contrast between the thorns and the cheerful red berries.)

Psychotherapy and Psychology

Knowledge, Skills, and Abilities of Successful Psychotherapists

Grandeur Peak

I have borrowed the phrase “knowledge, skills, and abilities” from the human resources field. Here is a discussion of the attributes that set successful therapists apart:

Collaboration: Competent therapists see themselves as working alongside their patients; effective therapists do not see themselves as applying treatment to their patients. Successful therapists view the patients as equal human beings, worthy of full respect and dignity, who have been entrusted to their care. These concepts take in Carl Rogers’ principles of empathy and “unconditional positive regard.”

Genuineness: Successful therapists care only about their individual patients during the sessions and convey that caring to the patients. Outside the sessions, competent therapists think about their patients respectfully and consider it an honor to work with them. Competent therapists never discuss their patients with others in a disparaging manner even if their identity is not betrayed. Sadly, I have encountered a few therapists who have spoken of patients in terms of demeaning nicknames or made fun of supposed foibles. Fortunately, therapists do not have to be models of behavior to be successful, but they do have to care deeply about their patients and about the the therapy process both in and out of the sessions.

Ethical Principles: When asked what the first principle of ethical behavior is, most therapists immediately say, “Do no harm!”; Actually that is second. The first principle is informed consent. Successful therapists assure that patients know the potential consequences desirable or not, of all aspects of therapy before participating. Just as psychotherapy is a powerful force for getting unstuck, it has the potential for miring patients even deeper.

I sometimes encounter patients whose stated reason for therapy is to work through a problem with a difficult situation at their employment, say, an abusive supervisor. During the course of history taking I might discover some significant childhood maltreatment that is not particularly distressing for the patient now. The treatment for resolving that trauma will unleash considerable upset before resolution. Because the patient is not asking for assistance about the trauma and the trauma is not an important factor now, I will let it go. Possession of a tool is not sufficient reason to utilize it.

Personal Success in Accepting Transitions, Loss, and Death: In the prior post I stated the goal of therapy is to get people unstuck. The experiences which get us stuck are denying the reality of transitions, loss, and death. By clinging to the past we cannot move into the future. Because successful therapists have a history of getting unstuck, they are further down the road as able companions to their patients during their adventures. In the end successful therapists have confidence in the process of getting people unstuck and convey that confidence to their patients. Competent therapists are enthusiastic about helping, and they do not shrink from the process or the patients.

Recommended Books: Here are three books which I consider essential reading for any therapist or aspiring therapist.

Emotional Intelligence by Daniel Goleman.
Give and Take by Adam Grant.
In the Company of Women: Indirect Aggression among Women: Why We Hurt Each Other and How to Stop by Pat Heim, Susan A. Murphy, and Susan Golant.

I like these books so much that I have both hard and digital copies. I recommend these three titles and authors exactly as I have written them above. In my opinion authors with similar titles provide incomplete reflections of the brilliance of these books and may be capitalizing without adding value.

Ending Thoughts:

It is worth repeating that ultimately patients heal themselves. Therefore, the mission of a therapist is to facilitate progress.
Successful therapists come to the field already demonstrating requisite knowledge, skills, and abilities. Graduate school, internships, residencies, fellowships, lifelong continuing education, and most importantly patient success enhance the knowledge, skills, and abilities. Being a successful therapist is not a threshold where one rests on one’s laurels.

I invite your comments.

Warm regards,

Dr. Michael

(The featured image is Grandeur Peak as seen from Sugarhouse Park in Salt Lake City.)

Psychotherapy and Psychology

Psychotherapy: An Introduction

Green Door at Tulloch Castle

What is psychotherapy?

Psychotherapy is the process of patient and therapist working together to get the patient unstuck. When I first saw patients 48 years ago, I realized that therapy was bigger than I was. That realization remains valid today. I have witnessed the power of therapy thousands of times. I began providing therapy in my twenties and still lacked many relevant adult experiences as result of my having been cloistered in Catholic priesthood seminary and in graduate school. In spite of my inexperience, the patients achieved their goals and enhanced their lives by therapy. These patients were often older than I and were married with families. Many had lived through wars, on the home front or on the battlefield, and had weathered economic recessions and even the Great Depression. They struggled under clouds of despair, anxiety, memories of domestic terror as children, psychoses including schizophrenia and bipolar disorder, and substance use. And as a result of therapy, they discovered their paths forward; they became unstuck.

So, what is psychotherapy?

Providing psychotherapy is an art that requires a myriad of explicit and intuitive skills. Those skills are acquired through individual study, classroom training, providing therapy under close supervision, and listening to patients. The classroom training is intense during graduate school but must be continued yearly throughout one’s career. Looking back I think I was a “good enough” therapist early in my career, but my proficiency has continued to grow. In spite of all, I have occasionally encountered gaps in my knowledge and struggled to get back on track with certain patients.

What is the role of the patient?

Although I take pride in my work, the patients are the stars of therapy. They bravely flounder in a state of beneficial uncertainty for weeks, months, and even years. Here is the secret: Patients ultimately heal themselves. My job is to set up a healing environment. The courageous work on the part of patients account for my early “successes” in providing therapy as well as my current satisfaction in still practicing.

What are my allegories for patient-therapist cooperation?

I use a metaphor and a story to illustrate the therapy process to my patients. First the metaphor: Needing therapy is like being lost in the middle of a tropical island jungle. Safety requires reaching a beach. The therapist has been parachuted into the island at the patient’s location. Neither the therapist nor the patient knows the way out. Each has knowledge, skills, and abilities that complement the other’s. Working together, they find the beach. In the next post, I will elaborate on the knowledge, skills, and abilities of a competent therapist.

Another story that illustrates therapy is the 1976 episode, titled The Hunters, from the Michael Landon series, Little House of the Prairie. An old blind man played by Burl Ives and the 9-year-old Laura played by Melissa Gilbert find themselves in an isolated mountain range. The old man and the little girl have to find a doctor to save the grievously wounded Charles Ingalls, the victim of an accidental gunshot. The old man had not been off the mountain for 30 years. By teaming up, the old man with his keen sense of smell and hearing rekindling his memory and Laura with her agility and eyesight find their way to help.

When I tell these two allegories to patients, they listen grimly but don’t object. When I try to lighten the mood by giving the patient the choice of roles in the second scenario, I am always assigned the role of Laura.

What is the mission for future posts?

The next post will address the characteristics of effective therapists.
Subsequent posts will highlight posttraumatic stress disorder (PTSD), autism spectrum, happiness, cognitive behavioral therapy (CBT), mindfulness, and beyond.
I expect this blog to have two types of posts, those pertaining to psychotherapy and health and those pertaining to scientific psychology. Spoiler alert: Scientific psychology is a hard science and much more than psychotherapy.

What is my invitation?

I eagerly look forward to your comments, questions, and suggestions for further posts. Of course, I would be honored if you signed on as a follower.

Warm regards,

Dr. Michael

About the featured image: A gate at Tulloch Castle on the Scottish Highlands. (Photograph by the author)

Uncategorized

On Becoming a Psychologist – Twice (and Other Things)

I have long desired to write a book or even a series of books about psychology. In fact in 2007 I retired entirely from the practice of psychology. I did keep my license current by participating in the required continuing education courses – 48 hours every two years. I was all set with a paid for house, a generous pension for life, and a younger spouse who was still employed as an executive. I immediately set to work on my first book which I tentatively titled, “On Becoming a Better Person.” As you can see I was paying homage to Carl Rogers and his groundbreaking book, On Becoming a Person, published in 1961. Two themes exist here: the first is Roger’s book and the second is my preoccupation with what it means to be a good person. Twelve years later that book still exists in infant form as neat pile of handwritten 5-1/2 x 8 inch index cards with carefully outlined chapters.

After 14 months of that retirement, I sorely missed the engagement in the world of employment with coworkers and meetings and membership on teams with goals bigger than one person could accomplish alone. Because I have had a lifelong devotion to food, I have acquired sufficient culinary skills to be called “chef” without blushing. I managed to land a job as a retail associate in the high end cooking store, Sur La Table in the Gateway District of Salt Lake City for $9.00 an hour. After a year of having grand fun as a retail associate working in the store of my dreams, I wormed my way into the position of chef instructor where I could teach culinary classes at the store. I was one of the very few nonculinary trained chefs that Sur La Table had ever hired. I taught a wide variety of classes in baking, pastries and hot kitchen. I was elated.

In the meantime I found my way back to the practice of psychology in 2010 through the generosity of Dr. Jon Bone, a brand new, very smart and very driven psychologist who was just establishing his private practice. He advertised through the Utah Psychological Association Forum that he was looking for a psychologist who could see patients in his new office space and pay a fee to help support the enterprise. I know that Jon was looking for a young person closer to his age of about 30, and I don’t know what he thought when an “old” man twice his age asked for the job. Anyway, Dr. Bone agreed and all I can say is, “Thank you, Jon.”

For almost a year I saw 8 to 10 patients a week and taught culinary classes at Sur La Table. I liked that my fee for providing one hour of therapy was about what I made for each cooking class which required about 6 hours of prep, teaching and cleanup even with assistants to help me. But, the classes paid me in mental health. Sadly, by the summer of 2010, my patient load forced me to make a choice between culinary and psychology. I loved psychology and reluctantly let go of teaching. I do want to acknowledge Executive Chef Kyle Nicholson who had the confidence to take me on even without formal culinary training. Chef Kyle was the same age as Dr. Bone, and they knew each other from their soccer team in elementary school. Thank you, Chef Kyle, for the opportunities and the knowledge you gave me.

Now you may be wondering where Carl Rogers fits into this narrative. Just a little patience and I will get there. Well, I spent almost the entire decade of the 1960’s in preparation for the Catholic priesthood. With great enthusiasm and in spite of my parents’ obvious reluctance, I trundled from Layton, Utah to Baltimore, Maryland and later Oak Ridge, New Jersey for a seven-year coming of age adventure in a boarding school/minor seminary in the quest of become a Paulist Father. If you are wondering what that was like, look no farther than Harry Potter and Hogwarts except, sadly, it was not coed. It was all there, the dining hall (refectory) with the head table, close friendships, and some conflicts with other students and with the faculty. Many of the faculty were priests from New York City of Irish heritage, and they did not like Italian boys like me. No worries: I was academically at the top of my classes, and I enjoyed the atmosphere so much that no one could spoil it for me.

My last months in the seminary were spent at the novitiate just outside of Oak Ridge, New Jersey. It was a monastic life of prayer and work and a year off from academic studies. While at the novitiate I had become increasingly aware of a desire to help people going through life’s difficulties with something more immediate than religion. But, I did not know what. Then, one Saturday night around December of 1967. I was alone in the extensive novitiate library and just wandering through the stacks and looking for a book to read. A title stared out me: On Becoming a Person by Carl Rogers. I absentmindedly removed it from the shelf and started to read it while I stood in aisle. The opening paragraphs floated off the page and overwhelmed me: Of course, I wanted to be a psychotherapist! I left the seminary, moved back in with my parents and eight younger siblings, and enrolled at Weber State University in Ogden with a declared major in psychology. I have never looked back.

As to the mission of this website. It will be a series of posts addressing cutting edge topics in both the academic science and the clinical practice of psychology. The posts will cover not only those book chapters from the index cards mentioned above but also discussions about psychology as a hard science, evolutionary psychology, neuroscience, history of psychology, and the scientific underpinnings of epistemology, ethics, aesthetics, logic, metaphysics, and politics.

About six years ago I moved my psychology practice to the Center for Human Potential (https://c4hp.com) where I work with a dozen wonderful colleagues. In honor of my 72nd birthday, I limited the practice to two days a week so that I can blog on two sites: This one and https://thecosmos.blog. I am extremely excited about beginning this blogging journey with you the readers. Thank you very much for signing on with me!