with the reality of severe autism:
General concepts for supporting emotionally fragile
individuals who display maladaptive patterns of
adjustment. How are care providers to support a
person who is not connected to others, who lives
in-the-immediate moment, who reflects and magnifies
other's emotions, and who has little continuity
2. Creating stability after meltdown.
What not to do after meltdown?
The role of the supporting caregiver is not to
attempt to "reason with" or "fix"
the person. At the moment of high arousal, the
role of the supporting caregiver is not to attempt
to identify "the reasons why".
One task for the supporting caregiver is to become
aware that the individual who is "testing"
his/her environment for safety will project their
fearful feelings into their caregivers.
Thus, without understand why, caregivers might
find themselves experiencing fear, arousal and
In an attempt to self-validate their fear/expectation
that the world is an unsafe place, some individuals
may attempt to evoke threatening responses from
their caregivers, which reinforce their "default"
core belief that the world is an unpredictable,
unreliable and threatening place to be. The task
of the caregiver is to understand this phenomenon
and to "finesse" the individual by not
playing into this.
The task and role for the caregiver is to be
a constant, reaffirming source to the individual,
and to not get caught up in their drama of the
What to do after meltdown?
A. "Correct" therapeutic goals, tasks,
roles and attitudes:
The goal for the supporting caregiver is to try
to cause the individual, who is experiencing disconnection
and detachment, to feel momentarily connected
and attached to their care provider.
The task and role of the supporting caregiver
is to assist the individual to feel safe, secure,
and bounded (responded to) by predictable, certain
responses. Become their guiding light through
the dense fog of their existence. Become their
The emotional attitude of the supporting caregiver
is to try to cause the person who is "mirroring
and magnifying" emotions to have a "smooth
and calm surface" to reflect.
"They are exquisitely context sensitive.
Whatever is going on right now is going to be
The caregiver's demeanour should be one of "compassionate
detachment" or "caring-lack of concern."
(That is, "lack of concern" about the
outcome of your own caring response. Offer what
you can but do not be affected if this is not
accepted by the person.)
This detached emotional orientation may allow
the caregiver to "deliver" a certain,
calm, predictable response without becoming "caught
up" in the individual's personal emotional
storm. Be like a warm, wood stove. Offer your
emotional "heat", but do not pursue
the person trying to get them to consume your
B. Trust and the front-line support worker: The
concept of supporting the individual in a "mental
While encouraging effort towards supported problem
resolution, a primary therapeutic role of caregivers
is to attempt to support the individual's self-acceptance
and self-forgiveness. The role of caregivers is
to attempt to "remove shame and self-blame."
Once a person has had a meltdown (decompensated,
fragmented and regressed) they will need to be
carefully assisted to reconstruct a connection
to their world and others in it. This will be
necessary before they can "go back"
to the way they were before they became overwhelmed.
In their fragmented mental state, the individual's
ability to function becomes the responsibility
of the care provider.
Caution: One role of the supporting caregiver
is to understand that "your own feelings
of frustration at your inability to help the individual
may feel like anger and rejection to the individual."
In-the-moment that you are looking at and talking
to a person who is in a state of reflective agitation,
you have to project that you really like the individual
you are supporting. This feeling must be genuine.
This is the challenge for caregivers supporting
such challenging individuals. It is hard to genuinely
like the person who has just destroyed your things,
hit you, or is blaming you and cursing at you.
Trust is established by empathizing with the
individual, acknowledging their anger without
retaliation, while at the same time reinforcing
The interaction between the individual and their
therapist is the:
"foundation for trust, object constancy,
and emotional intimacy. The therapist must become
a trusted figure, a mirror to reflect a developing,
consistent identity. Starting with this relationship,
the individual learns to extend to others appropriate
expectations and trust." (Kreisman &
Strauss, p. 125).
Licensed therapists have the training and the
time to assume these roles. This is a much harder
task for a care provider in a residential or work
setting. For front line care providers the answer
has to be much more rapid, systematic, and predictable.
The mechanics of beginning to build a sense of
trust and connection and inner consistency is
to build "rule oriented", predictable
and even ritualized interactions.
- Roles and boundaries need to be explicit and
defined for all the players.
- Actions and transitions can be bridged with
visual and concrete props.
When required to operate in the world outside
of such predictable, constructed interactions
the individual remains vulnerable. The long-term
goal is that, eventually these "mediated
and manufactured" interactions become a familiar
and genuine basis for relationship.
For the caregiver on the front line, the immediate
task and role is to be a "rock" the
individual can stand on. Support the individual
to be "successfully dependent" Do not
pressure the individual to perform all of the
time, what they may only be able to do when they
are calm and secure. Provide the calm and secure
environment that allows them to function.
When the individual you are supporting is in
an extreme state, it may help a care provider
to imagine that you are operating a "mental
health sanctuary." Assume the person is in
a chronic state that they may linger in for a
long period of time without getting "better".
In this mind-set, offer the individual support
until they are internally stable enough to re-engage
with the level of assistance that you are able
Nathan E. Ory, M.A.
Nathan Ory is a psychologist with the Island Mental
Health Support Team,
Reality of Severe Autism (pt 1)
Reality of Severe Autism (pt 3)