The angry patient with Asperger’s

The author’s observations

In a study in rural Appalachia, telephone reminders increased attendance at psychiatric intake appointments.⁴ Calling the group home before each of Mr. A’s appointments took extra time out of my schedule but improved Mr. A’s attendance rate.

In residential treatment of children, Monahan notes that childcare workers could contribute useful observations and benefit from the therapist’s advice.⁵ Establishing rapport with the staff at Mr. A’s group home helped me proceed with therapy.

TREATMENT Social skills training

In the second 4 months of therapy, Mr. A changes jobs to become a greeter in a local video game store. He is happy, and group home staff members are pleased they no longer spend 2 hours each day transporting him to his previous job.

Soon after, during a reminder phone call, a staff member tells me that Mr. A’s brother and father were murdered the prior week. Three staff members attend Mr. A’s brother’s funeral, which he appreciates. Mr. A refuses to attend his father’s funeral because of continued anger toward him.

When I ask Mr. A if he wants to talk about the deaths, he declines. I subsequently spend half a session discussing strategies to address grief,⁶ such as imagining a conversation with his deceased brother.

I decide to review Mr. A’s therapy goals because he still has a lot of anger toward his recently deceased father. I am concerned he might discharge this anger onto a staff member, coworker, or fellow patient. Mr. A states he wants to focus on relationships, especially his anxiety around women. He discusses his anxiety with starting and maintaining conversations with women.

I begin role-playing in sessions by pretending to be a woman for Mr. A to speak with, but he feels this is silly. I teach him exercises from a social skills training workbook developed for patients with Asperger’s, such as “Starting a conversation,” “Staying on topic,” and “Making eye contact” (Table 2).⁷ Mr. A says group home staff members occasionally take him out to a nearby nightclub and encourage him to talk to women.

To see how Mr. A behaves in public, during our sessions I take him to different parts of the hospital, such as the gift shop, library, and deli. I instruct him to ask various women non-threatening questions, such as how much a certain entrée costs. I note his body language, such as tilting his head down and fidgeting during conversations. I provide him with immediate feedback, which slowly increases his awareness of these behaviors.

With Mr. A’s permission, I educate the group home staff about how to point out these behaviors when Mr. A is in public. I ask them to focus on body language and emphasize that Mr. A needs to apply what I teach him to other settings.

The author’s observations

Patients with Asperger’s disorder need specific training to build a repertoire of social skills.⁷ Teaching in real-life settings helps patients generalize these skills.¹

Zimmerman⁸ discusses how caregivers might have an unrealistic, “magical” view of psychotherapy and feel suspicious of the process. With Mr. A’s permission, I ask group home staff members to meet with me for 10 minutes at the end of each of Mr. A’s sessions to make them aware of what is happening with his therapy. I want them to feel that they are an important part of Mr. A’s therapy. These meetings may have alleviated staff members’ fears about my time with him. Even though Mr. A granted me permission to disclose all details of our sessions with the staff, I was careful to not disclose sensitive issues, such as the patient’s dreams and fantasies.

TREATMENT ‘Fear’

Mr. A rates his anxiety as a 4/10 whenever he speaks with women. To more specifically understand his underlying cognitions, I use Kendall’s FEAR plan (Table 3).⁹