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This is a pre-publication version of the following article: D. Hawker (2017). Practising clinical psychology on the autistic spectrum. Clinical Psychology Forum, 294 (June 2017), pp9-13. The published version can be found in the journal issue available here.
Submitted for publication 3rd August 2016. Revision submitted 13th December 2016. Accepted 13th December 2016.
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The author describes his experience as a clinical psychologist with Asperger’s syndrome, including how he came to be diagnosed, and how his diagnosis affects his clinical practice.
Four years ago, in my early 40s, and eleven years after qualifying as a clinical psychologist, I was diagnosed with Asperger's syndrome. This was a confirmation of a self-diagnosis which had come as a slow surprise over many months. Diagnostic services for adults on the autistic spectrum had just recently been rolled out locally. The psychiatrist who diagnosed me said I was not the first clinical psychologist she had diagnosed, though I knew of no others who had received the diagnosis.
It has been a long journey to diagnosis. Since early childhood I found it hard to relate to my peers and felt an outsider in social settings. From adolescence onwards, my exploration of why this was drove my early academic and professional career. I filled my O-level text, Lord of the Flies (Golding, 1954), with notes on why central characters were scapegoated. I researched shyness and peer victimisation. During clinical training, a huge personal challenge, I decided I had (or was recovering from) social phobia. After qualification I worked in a children and families' team and became one of the few of my colleagues confident enough to diagnose autism. Diagnostic approaches have their drawbacks, but in general parents found diagnosis very helpful. It never seriously crossed my mind that autism could be a diagnosis I shared.
Asperger's syndrome and autism are best regarded as part of a spectrum rather than distinct disorders (Attwood, 2007). Many service users (including myself) prefer the possibly less stigmatising label of Asperger's. I will use the terms autism, autistic spectrum, autism spectrum disorder (ASD), and Asperger's syndrome interchangeably here.
When my four-year-old son was diagnosed with autism, I started seriously to wonder about myself. I had resisted his diagnosis earlier as I thought he would not have met diagnostic criteria, because his difficulties did not seem as extreme those I had seen clinically, and because he reminded me of myself at his age. Some of my family refused to accept the diagnosis for similar reasons - “He's no different to how you/we used to be”. Did this mean that I was as autistic as my son? Would my son adjust to his diagnosis better in time if he could know this?
I checked my Autism Spectrum Quotient (Woodbury-Smith et al, 2005). I read up recent literature on adult diagnosis. I talked with my wife (also a clinical psychologist) and some close friends. I went through the various sets of diagnostic criteria (see Attwood, 2007). I reconsidered my early life and more recent incidents in the light of criteria and how they might be displayed in adults. Pretty soon I had made a convincing case for my having almost all of the possible symptoms.
I had diagnosed myself. It was time to seek an independent opinion. It took over a year to find one, not that I minded waiting. When the psychiatrist offered an assessment at short notice, I called to ask if I could delay it until I had more time to prepare. She later said that my response itself, along with many examples from my life history, showed that I clearly met the criteria.
No supervisor or colleague ever suggested I might have Asperger's syndrome. The principal reason is probably that too little was known, until the last decade, about how it presented in adults. Even by then, my wife and I were sceptical about several friends' identification of themselves as autistic. Like many of them, I had learned to compensate for my symptoms so that I could pass as neurotypical (without ASD) to colleagues who were surprised by my diagnosis. Others who were not surprised may have recognised, rightly, that I was not ready to disclose or consider my own pathology. It is good to read that diagnosis is not now an immovable obstacle to training (Muggleton & Johnston, 2016), but I suspect it would have put me off trying. My supervisors and others helpfully gave me feedback on behaviour which impaired my clinical work and which were also symptoms of ASD. It was only by adapting my behaviour in response that I ever gained a training place and achieved clinical competence.
In my early twenties, two university Nightline services rejected me as a volunteer because of my poor eye contact and other odd non-verbal communication. Samaritans trainers observed the same problem but gave me time to improve. I practised making eye contact with my postgraduate officemate, who later became my wife. Before my diagnosis, I attributed my poor eye contact to strabismic ambliopia, the lazy eye squint that had affected my vision since birth. With a supervisor’s encouragement, I asked clients for feedback on how my squint affected therapy. Most had noticed it, but all said it had not harmed the process. For some, it almost seemed as if recognising one of my problems gave them more confidence that they could overcome their own. It made me less threatening.
This was an important message, giving me some confidence that I could be an effective therapist despite communication deficits. And I needed social confidence. Often known as quiet, particularly in my early weeks in new teams, I tend to mumble when unsure. A school friend once said I would never have a career in conversation. On the first day of training, our course director assured us not to worry about what lay ahead, as clinical psychology is essentially about having conversations for a living. I could not have been less reassured.
But I had begun to learn about having good conversations in a clinical context. An assistant psychologist post in psychiatric rehabilitation helped me learn better ways of relating to service users. Two refused to speak to me after I asked too many challenging questions. I learned to rebuild collaborative therapeutic relationships by becoming more selective about my questions, and mixing them with less threatening small-talk and low-level self-disclosure. Later, placement supervisors observed that I intimidated colleagues with threatening questions and a superior manner. I had to learn to extend to professionals the warmth and empathy I showed clients.
Autism made it hard for me to become a clinical psychologist, but also made it possible. See Muggleton and Johnston (2016) for a detailed reflective account of this paradox. Long before I was diagnosed, the experience of living with a disabling mental health condition first interested me in psychology and directed me along a clinical route. Not implicitly understanding social rules, I tried to articulate them explicitly to myself as an observer of behaviour. Aged six, I dreamed of putting up information boards in my school playground describing the playground games I watched. I felt a natural affinity and empathy with people who struggled at the edge of normality. My desire to understand outsiders helped me become an expert in peer relationship difficulties, and awakened my interest in people with a whole range of psychological disorders. As a trainee, I easily empathised with clients’ negative self-image. I treated social phobia less pervasive than my own, not realising it is a common secondary diagnosis to ASD (Attwood, 2007). As an early experiential training exercise, we were asked to record negative automatic thoughts one evening. As far as I recall, fellow trainees reported having between three and ten negative thoughts, or forgetting to do the exercise. I counted 29 on my two-mile cycle ride home.
I do not easily guess others’ thoughts, but have long compensated for my poor theory of mind by training myself to imagine and understand the thinking that may have led to different points of view. I am often slow to judge, and willing to explain other people’s distasteful, bizarre, or contradictory beliefs. This gets me into trouble at times, but is also a very useful clinical skill in understanding viewpoints different from my own, giving me – according to at least one colleague - good metacognitive awareness.
Distrusting my own social competence, I was able to accept and learn from negative feedback about my social communication. Criticism shamed and filled me with negative thoughts like, “I should be able to do this by now.” But ultimately I tended to accept it at face value instead of becoming defensive, and used it to improve instead of giving up. One interviewer was both surprised and impressed, after giving me extensive feedback on why I had not been appointed, to discover I had been offered the next post I interviewed for. The explanation was simple: she showed me how to change my interview technique. In fact, though criticism was always hard to hear, I craved a professional training such as clinical psychology that would teach me how to improve my social communication and behaviour. With good supervision in place, making social mistakes simply gave me more opportunities to learn. My efforts to repair professional relationships I have damaged have often made those relationships stronger than they would have been otherwise.
I generally find clinical conversations far easier than informal conversations in groups, pubs, and parties. Colleagues have commented that I often ask questions which penetrate to the root of a problem, perhaps being less inhibited by concerns about others’ reactions. Not naturally filling silences makes me a good listener, though I also have to be aware of clients unnerved by silence. Most clinical work involves putting on a persona and following a script. Many people with ASD are good at mimicry. I love being on stage. Scripts and roles come easily to me. One Samaritans training session involved practising the tone and words for answering the telephone. From my first attempt, my training partner said I sounded exactly like the volunteer who first answered the phone to him. Scripts are flexible, their wording can be varied to suit the audience, and they are open to improvisation. Assessments and various types of therapy follow fairly standard scripts. New clinical problems can be prepared for, when I make time to devise a good plan. Even when I go off script there are familiar lines to follow. So long as I am confident with my material, talking to small or large groups does not scare me.
I have also often been conscious of putting on a persona in everyday life to compensate for ASD. When I feel accepted into a social group and my quietness wears off, people usually come to know me as slightly odd. Then it becomes easier to do or say slightly odd things, as if to exaggerate my persona. Asking, saying, or doing the unexpected, to disrupt dysfunctional assumptions and entrenched behaviour patterns, are important functions of clinical psychologists in many clinical settings, especially in systemic work and teams. It helps that I have the confidence to do it and some experience to know when it might, or might not, help.
Autism also brings with it strengths of intense focus, organisation and rigour, all useful skills for a clinical psychologist. My favourite approach to stubborn problems is to keep attacking them until they submit. Whilst I had to work hard at many clinical aspects of training, I was much more confident with the academic and research components. Once I started paying proper attention to them, statistics were among my strong points. I learned to do meta-analyses. I found a great deal of satisfaction in mastering touch-typing, wordprocessing, data entry, computer systems, and statistical software. I recall details well. I am comfortable following safeguarding and other rules when rules need to be followed. Supervisors complimented me on the quality of my organisation (though “in a disorganised way”, as one put it), my written communication, and my formulations. Curiously, it was several years after qualifying that I began to wish I had honed the latter skills more. Because I never had to work so hard at them, they had not improved as much as my social communication skills did during training.
Before my diagnosis, I diagnosed several people with autism, often spotting signs of it that colleagues missed. I believe I also failed to recognise that several clients had ASD. I am sorry I let clients down, and I hope they have by now managed to find a better informed clinician. Since my son and I were diagnosed, I have become much more attuned to recognising symptoms and assessing ASD in all its diversity. Clearly I have to guard against the opposite tendency to overdiagnose. I have learnt the importance of keeping up with the constantly growing literature on autism.
Disclosing my diagnosis is often helpful when discussing the diagnosis with clients and families, particularly when they find their diagnosis hard to accept. It is good to show that autism need not be a barrier to successful training in a caring profession. I am learning when to disclose and when not to.
Accepting my diagnosis has improved my response to negative feedback. Now I can attribute social mistakes to my disability, it takes less emotional effort to face trying to correct them. Greater awareness of the likelihood of social communication failures also sometimes helps me prevent them.
I have become more aware of my blind spots, such as clinical observations I may miss, covert intentions I may not recognise, communications I may mishandle, unsettling nonverbal behaviour, and fixed plans that need reformulating when setting conditions change. I know where I need to put more efforts and consult with colleagues to compensate for my limitations.
My diagnosis has awakened me more to the service users' experience that I too often neglected. Autism has a very active user community which I have joined as a member of the National Autistic Society. Reading their material makes me aware how many people's experience is different from mine. I must acknowledge that I have it easier than many service users, am more neurotypical than many on the autistic spectrum, and so still do not understand every other person with ASD or how hard it is for everyone. My own challenges are not identical even to my son’s. My diagnosis gives me some understanding and insight into others’ experience, but I cannot claim too much for it. It would be most interesting to hear more psychologists' experiences.
Attwood, T. (2007). The complete guide to Asperger’s syndrome. London: Jessica Kingsley.
Golding, W.G. (1954). Lord of the Flies. London: Faber & Faber.
Muggleton, J., & Johnston, K. (2016). ‘You’ve hired a psychologist with autism?!’: Reflections on being a trainee clinical psychologist with autism. Clinical Psychology Forum, 288, 5-8.
Woodbury-Smith, M., Robinson, J., & Baron-Cohen, S. (2005). Screening adults for Asperger syndrome using the AQ: Diagnostic validity in clinical practice. Journal of Autism and Developmental Disorders, 35, 331-335.