Psychotherapy Hates Autism
What I mean here is that the process of psychotherapy as generally understood and undertaken often seems itself to be a collection of stressors that only make me feel worse. Certainly, that’s been my most recent experience.
(Notwithstanding the “consultive exam” the Oregon Department of Human Services sent me to as part of Social Security’s disability determination process, I’ve never felt that any particular therapist was campaigning against my autism.)
In trying to break up with my therapist this week, she said exactly the wrong thing: “Therapy can be hard.”
Yes. I know that. Of course I fucking know that.
There’s a difference, however, between, “Therapy can be hard.” and, “The socially performative nature of therapy can be especially stressful for people whose condition can be in large degree about social communication and performance distress.” If a therapist doesn’t see this, I don’t know what they are doing.
For me, that statement—“Therapy can be hard.”—is at least a distant cousin to something else I encountered again recently.
Am I the only one who when I express to someone how this or that is difficult for me or hard on my brain, and that someone goes, “That happens to me too.”, you get kind of pissed off? Like, no, what I’m describing doesn’t happen to you.
It always reads to me like, “Oh, we all have hard days.” or, “Oh, we all get tired.” Yes, everyone does. But the way my days are hard, and why they are hard, and the way I get tired, and the why I get tired, are different. Stop negating that.
Sometimes I think, you know, you wouldn’t say to a person with emphysema, “I cough sometimes, too.”, but apparently it’s okay to assume your every day troubles, legit as they are, equate to my brain’s wiring, and, no, sorry, they don’t.
Sitting on display in an enclosed space engaged in a socially performative exchange with someone whose job is to interrogate you all while they make determined eye contact, this is not a process you’d imagine people wanting to help the Actually Autistic would devise were they trying to design a therapy process specifically for that population.
Surely psychology has room for the idea that the very form therapy takes should take into account the issues and impairments of the patient?
(I’m currently participating in a study of autistic burnout, and guess what? The researchers specifically allow for different communications methods and channels. I’m participating via email, even though the researchers are local.)
There are, of course, other approaches, including the minor explosion of “online therapy” services that range from video chat to messaging to email. Some of those are even covered by private insurance, but so far as I know none of them are covered by the Oregon Health Plan.
Laws like the Americans with Disabilities Act require businesses and service providers to accommodate disabilities, impairments, and differences. It would be nice if services like psychotherapy acted as if precisely the sorts of people those services are meant to help might have vastly different needs in terms of how they can engage successfully in the processes. It would make sense to me for in-person sessions to be part of most approaches to therapy, but for it to be the regular, primary form of engagement often feels like too big a hurdle.
There’s a difference between therapy that’s difficult but in the end rewarding and therapy that just leaves itself sitting atop the pile of other existentially-exhausting baggage one already is carrying around. Or, at least, there’s got to be a difference, right?
Discomfort is one thing, distress is another. I’m simply not willing to subject myself by choice to more distress than I am already under.
Even outside the high-pressure situation that is a therapy session, face-to-face conversation in real-time frequently requires too high an expense for too little a payoff. Monotropism makes clear that the sort of multitasking required for such engagement is a virtual impossibility. Like many autistics, I simply cannot simultaneously listen to the person talking to me, have thoughts about what they are saying, remember what they are saying, and have thoughts of my own that I want to bring up at some point during the conversation.
I defy anyone to say that’s a dynamic conducive to a productive, informative therapy session, let alone an ongoing therapeutic relationship.
Guess what works better? Email, where there’s a clear record of what’s said that can be returned to and looked back at. Messaging works, too. It might still technically be “real-time”, but less so than meeting in person, with more room for the autistic patient to understand what’s being said to them, and what they themselves want to say. Like email, there’s also a record, beyond the therapist’s notes and your own attempted memory.
Asynchronous beats synchronous, almost every time.
I need a therapist whose practice permits them to meet me halfway. I need to be able to do much of my therapy online instead of in-person, with in-person check-in sessions every now and then. I need to be able to ask a therapist to replace an upcoming session with them taking the time to read what I’ve been writing online about being autistic in the time since our last session.
Alternatively, I believe that therapists need to accept the idea of having homework. It’s not enough to do a spot review of earlier notes right before a session. I need someone who is going to prepare, ahead of time. They expect me to prepare, and while the patient-therapist dynamic of necessity is a somewhat imbalanced one, I do not believe it’s somehow a one-way street. I have months of writing about being autistic. I would like to believe that part of therapy is your therapist making sure to learn what’s come before them, but the way in which that happens simply cannot be me trapped in a room methodically reading aloud.
Right now, I am probably out of luck. After three sessions with my latest therapist I still feel like there’s just a huge communications gap that I am not convinced can be closed, and I can’t spend the next run of sessions just trying to fix that problem. That seems like a waste of everyone’s time. I know it feels like a waste of mine.
Maybe I should just go back to sitting zipped up in a winter coat. At this point, I feel like that would be just as effective.