7. Aspergers Syndrome- Rote Learning - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Off, Odd, Different… Special? Learning Disabilities, ADHD, Aspergers Syndrome, and Giftedness in Couples and Couple Therapy
Chapter 7: ASPERGERS SYNDROME – Rote Learning


Individuals with Aspergers Syndrome (AS) or Aspergers Disorder (AD) may gain adulthood with without ever been diagnosed accurately.  They may have never been formally diagnosed with any specific issues, having more or less flown under the professional radar.  An individual such as Brody may have more or less extreme manifestations of the characteristics of the syndrome, some or many attributes, and/or received negligent, ineffective, to outstanding support for its challenges.  Subsequently, some individuals may never been seen other than as a bit quirky or eccentric.  Interestingly, the subjective sense of such individuals as being off or odd may be the best diagnostic clue for the diagnosis of Aspergers Syndrome.  While such individuals may suffer quite a variable degree of functional impairment, relative success academically or vocationally along with being perceived as a bit off or odd is common for many Aspergians.  On the other hand, individuals with Aspergers Syndrome are often misdiagnosed as children as having ADHD or some other disorder.  Treatments may be ineffective because while Aspergers Syndrome rooted behavior may appear similar to behavior driven some other issues.  Although observed behavior may be similar, the behavior comes out of different causes.  Individuals with Aspergers Syndrome often experience common misdiagnoses in addition to ADHD, including Oppositional Defiant Disorder, Bipolar Mood Disorder, Conduct Disorder, Schizophrenia, Obsessive Compulsive Disorder, and Depression.  Misdiagnosis can occur because some features of Aspergers Syndrome are shared with other disorders, Aspergers Syndrome is comorbid with other disorders, and/or some professional are unfamiliar with Aspergers Syndrome.

Professionals may focus symptoms or characteristics that Aspergers Syndrome that are shared with other conditions and subsequently, assume them to be from a more familiar diagnosis.  The therapist for example may focus on specific behaviors common to other disorders, and not notice a fuller spectrum of the individual's behavior.  This can result in the therapist not noting how an individual's greater array of behaviors corresponds to an Aspergers Syndrome diagnosis.  "Considering the impact that a misdiagnosis of AS can have on children and families and the lack of literature on AS in the family therapy field, it is important to evaluate MFTs' ability to accurately diagnosis this disorder. (Carlson et al., 2007, page 29-30).  Dr. Luke Tsai, (Professor of Psychiatry and Pediatrics at the University of Michigan Medical School and the Director of the Developmental Disorders/Autism Program at the University of Michigan Health System) states, "If the medical centers or hospitals where these physicians were residents training do not have a special program for ASD, the physicians may have very few, if any, opportunities to learn how to provide medication care to persons with Asperger disorder.  Unfortunately, learning about the medical and mental health care of persons with ASD occupies a very low status in the training priorities of pediatricians, neurologists, and psychiatrists, in the United States," (2001, p.6).  Professionals, including pediatricians, teachers, and therapists are often ill prepared to help, frequently having only cursory knowledge of Aspergers.  Educators and therapists may lack academic or professional training about Aspergers Syndrome.  In a study of 171 American Association of Marriage and Family Therapy member only 20.5% were able to diagnose Aspergers Syndrome (Carlson et al., 2007, page 33).

Professional and general communities often only gain knowledge through necessity as individuals show up in their practices or life and, finally become identified.  That is, if they are identified correctly rather than misdiagnosed as having some other issues.  In addition to potential combinations of two or more issues such as cultural differences, physical issues, learning disabilities, ADHD or ADD, Aspergers Syndrome, or gifted abilities, an individual can also have family or other environmental experiences or challenges.  As the therapist may diagnose Aspergers Syndrome inaccurately as ADHD, he or she may also misdiagnose the individual or couple such as Brody and Faith with a psychodynamic or a systemic issue primarily or exclusively.  Individuals may be very difficult to work with because of highly problematic and social inept compensations developed to counter accumulated psychological damages associated with having Aspergers Syndrome.  Brody was as difficult to deal with in therapy, as Faith was cooperative.  The difficulty as expressed in psychological mechanisms including defense mechanisms and personality disorders may draw the attention of the therapist away from the Aspergers Syndrome that may be the root of the psychological mechanism.  While Brody was relatively easy to misdiagnose for the therapist, the therapist had difficulty getting Brody to understand complex emotional issues, especially when using metaphors and analogies.  Depending on personal style and/or theoretical orientation, a therapist might use a lot of metaphoric and analogous communication in therapy.  This may be a mismatch since individuals with autism tend to have difficulties understanding non-literal speech.  This includes indirect requests, sarcasm, jokes, and metaphorical expressions.  Faith used a lot of indirect communication.  Indirect communication styles are common with individuals from traditionally disempowered communities or erratic emotionally traumatic family experiences.  And, indirect communication is often misunderstood by someone with Aspergers who tends to be much more literal.

DSM CRITERIA FOR ASPERGERS DISORDER
Individuals normally develop the ability by four years old to recognize that a person is thinking from the person's facial expression.  When a person is thinking, his or her eyes look away from a viewer to up to the left or right.  Without a particular thing to view, people assume the person must be thinking about something- "a clear demonstration that symptoms of a cognitive mental state were observable in the face, in this case the eyes"(Baron-Cohen et al., 1997, page 312).  Individuals with autistic issues including Aspergers Syndrome are able to recognize basic mental states from facial expressions, but have trouble with more complex mental states.  "at a more subtle level… there is a nonverbal communicative channel corresponding to… 'the language of the eyes'.  From the present results, it seems we are highly adept at comprehending this unspoken language, whilst people with autism or Asperger Syndrome experience considerable difficulty in decoding this. (Baron-Cohen, 1997, page 328).  They may recognize basic mental states such as happy or sad from noticing a more obvious smile or frown from the mouth.  They have significant difficulty recognizing mental states from looking at another's eyes however.  The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition functionally describes Aspergers Syndrome without speculating extensively on its causes.

A. Qualitative impairment in social interaction, as manifested by at least two of the following:

(1) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

(2) failure to develop peer relationships appropriate to developmental level

(3) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)

(4) lack of social or emotional reciprocity

B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

(1) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

(2) apparently inflexible adherence to specific, nonfunctional routines or rituals

(3) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)

(4) persistent preoccupation with parts of objects

C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.

D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years).

E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.

F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.

The DSM V has removed Aspergers Syndrome and Pervasive Developmental Disorder as separate diagnoses- a move that has been met with controversy among professionals.  Aspergers Syndrome would be considered or labeled under the more inclusive diagnosis of Autism Spectrum Disorder (APA, 2013).  Currently, or by history, must meet criteria A, B, C, and D:

A. Persistent deficits in social communication and social interaction across
contexts, not accounted for by general developmental delays, and manifest
by all 3 of the following:

1. Deficits in social-emotional reciprocity

2. Deficits in nonverbal communicative behaviors used for social interaction

3. Deficits in developing and maintaining relationships

B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:

1. Stereotyped or repetitive speech, motor movements, or use of objects

2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal
behavior, or excessive resistance to change

3. Highly restricted, fixated interests that are abnormal in intensity or focus

4. Hyper-or hyporeactivity to sensory input or unusual interest in sensory aspects
of environment;

C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities

D. Symptoms together limit and impair everyday functioning.

SIX CORE CHARACTERISTICS
Stephen Bauer, M.D. (1996), cited the work of Christopher Gillberg, a Swedish physician who describes six criteria that laypersons are likely to observe or recognize.

Social impairment with extreme egocentricity, which may include:
inability to interact with peers

lack of desire to interact with peers

poor appreciation of social cues

socially and emotionally inappropriate responses

Limited interests and preoccupations, including:

more rote than meaning

relatively exclusive of other interests

repetitive adherence

Repetitive routines or rituals, that may be:

imposed on self, or

imposed on others

Speech and language peculiarities, such as:

delayed early development possible but not consistently seen

superficially perfect expressive language

odd prosody, peculiar voice characteristics

impaired comprehension including misinterpretation of literal and implied meanings

Non-verbal communication problems, such as:

limited use of gesture

clumsy body language

limited or inappropriate facial expression

peculiar "stiff" gaze

difficulty adjusting physical proximity

Motor clumsiness

may not be necessary part of the picture in all cases

Bauer notes that Aspergers Syndrome shows a range of symptom severity meaning less impaired individuals and children may meet criteria but not get diagnosed.  They seem a bit unusual, different, or may be misdiagnosed with ADHD and emotional disturbance.  Aspergers Syndrome individuals and children may laugh or giggle, when others show embarrassment, discomfort, or sadness.  Adults and peers often misinterpret this response as Aspergers Syndrome individuals and children mocking or otherwise disrespecting their feelings or thoughts.  They often have difficulty conveying disturbance, anxiety, or distress.  Sometimes Aspergers Syndrome children have delayed reactions stemming from events that occurred much earlier.  "The child may worry about something, not communicate his or her feelings to parents and eventually, perhaps hours or days later, release the build up of emotions in a 'volcanic' emotional explosion.  Such children keep their thoughts to themselves and replaying an event in their thoughts to try to understand what happened.  Each mental action replay causes the release of the associated emotions and eventually the child can cope no longer.  The frustration, fear, or confusion has reached an intensity that is expressed by very agitated behavior" (Attwood, page 132).  Adult functioning would greatly depend on how successfully the individual has come to understand his or her challenges and whether he or she has developed effective compensations.  The adult individual who does not self-monitor or self-regulate his or her Aspergers tendencies tends to miss social cues with others, act irrationally to others, and may suffer social rejection.

DIFFICULTY INTERPRETING MENTAL STATES
Individuals such as Brody may over-learn certain compensations resulting in "odd" responses.  Jolliffe and Baron-Cohen (1997) discussed the responses of verbal adolescents and adults with autism of varying intellectual abilities who were presented with a set of vignettes where people say things they do not literally mean.  Actual motivations may be distinguished by many factors such as the preceding context, emotional expression, and the relationship between the speaker and hearer.  They used stories that non-autistic individuals would usually interpret motivations in only one way (page 395).  The researchers presented mentalistic stories and physical stories to autistic spectrum and non-autistic individuals.  For example,

The Mentalistic Stories

Banana
Katie and Emma arc playing in the house.  Emma picks up a banana from the fruit bowl and holds it up to her car.  She says to Katie, "Look!  This banana is a telephone!"
Is it true what Emma says?
Why does Emma say this?
Picnic
Sarah and Tom arc going on a picnic.  It is Tom's idea, he says it is going to be a lovely sunny day for a picnic.  But just as they are unpacking the food, it starts to rain, and soon they are both soaked to the skin.  Sarah is cross.  She says, "Oh yes, a lovely day for a picnic alright!"
Is it true, what Sarah says?
Why does she say this?

The Physical Stories

Army
Two enemy powers have been at war for a very long time.  Each army has won several battles, but now the outcome could go either way.  The forces are equally matched.  However, the Blue army is stronger than the Yellow army in foot soldiers and artillery.  But the Yellow army is stronger than the Blue army in air power.  On the day of the final battle, which will decide the outcome of the war, there is a heavy fog over the mountains where the fighting is about to occur.  Low-lying clouds hang above the soldiers.  By the end of the day the Blue army have won.
Why did the Blue army win?

Glasses
Sarah is very long-sighted.  She has only one pair of glasses, which she keeps losing.  Today she has lost her glasses again and she needs to find them.  She had them yesterday evening when she looked up the television programmes.  She must have left them somewhere that she has been today.  She asks Ted to find her glasses.  She tells him that today she went to her regular early morning keep fit class, then to the post office, and last to the flower shop.  Ted goes straight to the post office.
Why is the post office the most likely place to look?

Autistic spectrum individuals often did not recognize the appropriate mental state term for a story's context.  They made significantly more mental state justifications that were not appropriate for the context and fewer ones that were context appropriate.  Aspergers Syndrome individuals did better than autistic individuals but not as well as non-autistic individuals.  "The errors made by clinical participants were striking.  In the sarcasm story, one participant said that the lady's statement that it was a lovely day for a picnic was her "pretending that everything was OK in order to make Tom feel happier."  Another participant explained the utterance in the pretend story as "a joke."  When individuals with Aspergers Syndrome refer to others mental states, they have difficulty providing explanations of their causes, or the relationship between mental states and resultant behavior.  "people with AS did not elaborate or link the emotion of the character to a particular event that had occurred in the story.  Their reference to the mental states of a character may thus reveal a limited understanding of what they really stand for" (Colle et al., 2008, page 38).  As predicted, both groups of clinical participants performed normally on the Physical condition, where they were required to justify why a particular action had occurred (Jolliffe and Baron-Cohen, 1997, page 402).  In the Physical stories, the mental state of individuals were not important to the determinations.

One type of question asks for comprehension- whether the character's statement is true, while the other asks for justification- why the character made the statement.  The comprehension questions require a simpler level of interpretation, while the justification question requires a higher level of interpretation.  The comprehension questions ask individuals if the character's statement is consistent with the content of the story. The justification questions require individuals to integrate the character's statement with the story context.  An accurate answer needs to be appropriate to the context in the story.  Participants with autistic spectrum issues in the study readily detected that that a statement did not fit the situation, but had problems giving a contextually appropriate explanation for why the character said what they did.  When individuals did not ascertain or use the context, they "…tended to focus on the utterance in isolation.  This resulted in them tending to generate a locally coherent rather than globally coherent answer.  So, for example, a participant with autism who explains the white lie as a joke may be failing to use the story context to inform his answer.  Thus, this individual would be making an inference about how a character could have felt but not how he/she actually felt.  This is consistent with Frith's (1989) hypothesis that individuals with autism have a preference for processing locally rather than globally.  This tendency to process locally rather than globally has been demonstrated in a recent paper, where those with autism or Asperger syndrome attempted to justify a character's action by giving a locally rather than globally coherent inference (Jolliffe & Baron-Cohen, 1998a) (Jolliffe and Baron-Cohen, 1997, page 403).

Other people including romantic partners who assume that individuals have gotten and integrated the context may be mystified at the response.  Or, they may assume individuals are being purposely obtuse because their attention focused on elements that others would consider relatively insignificant.  This fit Faith's experience with Brody.  In the conversation about magazines, Brody honed in on her mention of the Great Wall of China and took off on the technology issues in China restraining open communication.  Brody missed her implicit energy of excitement and wish to share her interest.  Difficulty in responding may be from problems inferring a speaker's intended meaning or a "problem in appreciating some of the mental states employed in the Strange Stories test" (page 405).  "Results showed that individuals with Asperger Syndrome (AS), when compared to general population controls, had more difficulties in recognizing mental states from both faces and voices.  In addition, participants with AS recognised fewer mental state concepts then controls.  In twelve out of the twenty emotions and mental states tested in the CAM, a significantly lower number of participants with AS successfully recognised the concept, compared to age and IQ-matched controls… The strong negative correlation of the CAM scores with the participants' Autism Spectrum Quotient (AQ) score (Baron-Cohen et al., 2001) supports the relevance of emotion and mental state recognition difficulties in high-functioning adults with autism spectrum conditions.  These are important components of empathizing (Baron-Cohen, 2003).  Despite their ability to recognised basic emotions, such adults still find it hard to "mindread" complex mental states from faces and voices. (Golan et al., 2006, page 178).

Individuals with Aspergers Syndrome make more mistakes missing subtleties in facial cues and voice intonation while answering according to the content.  "When looking at the group differences on individual concept recognition, the deficit among the AS group in recognising insincerity is most striking.  Less than a third of the AS group members recognised this mental state successfully, which supports evidence from other studies, showing specific difficulty in understanding deception (Baron-Cohen, 1992; Sodian & Frith, 1992)" (Golan et al, 2006,, page 179).  Recognizing when facial cues are inconsistent with some intention can be very difficult for autistic spectrum individuals.  It may be that they are drawn to what is said, rather than noticing verbal intonation.  More obvious facial expressions such as smiles may be more familiar and relatively easier to recognize than more nuanced facial, posture, and other non-verbal cues that be incongruent.  Individuals with Aspergers Syndrome also have difficulty with recognizing subservience, dominance, and submissiveness.  

Since dominance hierarchies are widely recognised in social primates (De Waal, 1998) it is surprising that people with AS should find this emotion difficult.  However, it may be that nonhuman primates rely on other cues to judge dominance and subservience (e.g. physical size or success in conflict).  It is likely that people with AS would have no difficulty in understanding social hierarchies from non-emotional cues (such as rank). It may therefore be that their deficit arises only when the cues are from emotional expression.  Such misunderstanding of hierarchical human systems and social relations might, for example, lead to the use of an inappropriate attitude towards authority. (Golan et al, 2006, page 179).  While modern American couples more than ever overtly assert egalitarian relationships, hierarchal issues remain endemic to partnerships.  Difficulty recognizing hierarchy, dominance, submissiveness, subservience, and thus acceptance or contentment predict relationship distress.  Almost all non-Aspergian participants could recognize distaste from the disgusted group of emotions, but close to half of participants with Aspergers Syndrome could not.  More than a third mislabeled a disgusted facial expression as "offended" and two thirds mislabeled verbal disgust ("you've done it again") as "battered."  Distaste, which is more subtle than disgust is also difficult for individuals with Aspergers Syndrome to recognize (page 180).

Individuals with Aspergers Syndrome are also challenged in recognizing a foundational emotional condition for relationships- intimacy.  "More than 40% of participants with AS mislabeled intimate face items as 'determined' and 'carefree'. Similarly, 30% of them mislabeled an intimate voice item as 'subservient', possibly relying on its content (''ask me anytime'') while not picking up the intonation (page 179).  Difficulties distinguishing genuine closeness and interest from politeness or even boredom bode poorly for relationships.  Missing resentful, grave or mortified emotions with partners also may reflect previous peer problems in childhood.  People usually give cues to others when actions start to be uncomfortable.  Recognizing discomfort would prompt the socially conscious and conscientious peer to self-examine his or her behavior to determine what might be off-putting.  The socially competent peer would then adjust or stop disturbing behavior.  This was exactly what Brody did not do well with Faith.  Rather than adjusting or stopping, Brody often continued full speed ahead, unknowingly pushing Faith from mild annoyance to anger.  While virtually all members of the control group recognized the emotional concept of "uneasy," 38% of the Aspergers Syndrome did not.  Recognizing uneasiness requires picking very subtle versus gross degrees of emotions.  Uneasiness is a variation of the emotion of fear.  Golan et al (2006) discussed "A new fMRI study of the amygdala, a key brain area underlying the detection if fear in others, involved showing pictures of people expressing fear at different intensities to individuals with AS and controls (Ashwin, Baron-Cohen, Wheelwright, O'Riordan, & Bullmore, submitted).  Amygdala activation among the participants with AS was significantly reduced relative to controls.  Furthermore, the AS group showed no difference in amygdala activation between intense, moderate and mild degrees of fear.  This study supports the amygdala theory of autism (Adolphs et al., 2001; Baron-Cohen et al., 2000; Howard et al., 2000) and shows that the brain in high-functioning adults with autistic spectrum conditions does not respond differentially to expressions of subtle fear.  Our study is consistent with these findings (page 180).

Individuals across the autistic spectrum share a lack of spontaneous seeking to share their enjoyment and interests with others.  They seem to not understand people collaborating to share and coordinate their experiences.  Gutstein and Whitney (2002, page 165) cited research that show that as infants and toddlers within the autistic spectrum, young children already show different social development.  Children with Aspergers Syndrome tend not to spend the extensive time other children spend experimenting and practicing relationship skills with others.  As they become teenagers and adults, their interests, motivations, and social skills and intellectual processes become ever more distinguished from others.  Their social thinking process become distinct from other's process without the study and mastery of reciprocal, experience-sharing relationships.  Individuals with Aspergers Syndrome often persist interacting socially but without proficiency in experience sharing.  They do "not conduct the extensive personal research and self-discovery by which typical children become such experts at relationship building and maintenance" (page 165).  They split off their personal experiences from social experiences.  By the end of one year, typical children in exploring the world discover unique perceptions and experiences they share with others.  New experiences are exciting to share with others through initiating joint attention with peers.  Children and later adults with Aspergers Syndrome initiate joint attention less frequently.  As a result, they do not integrate their personal experiences with their greater social world, "to the detriment of both (Mundy et al., 1993).  This divergence appears to be highly stable through development.  For example, in one study, failure to initiate joint attention and emotion-sharing were the main factors still clearly distinguishing children with HFA from others by the onset of middle school years (Travis & Sigman, 1998)" (Gutstein and Whitney, 2002, page 165).  It is no surprise that in couples with an Aspergers Syndrome partner, the non-Aspergian partner often complains about their living parallel lives without much more than some functional interaction.  The Aspergian partner seems not to pay much attention to the partner.  As such, the Aspergian partner often does not coordinate social actions and emotional experiences.  From very young ages, children with autism do less monitoring and observing peer behavior.  "They rarely shift eye gaze between objects and partners, and they do not point to or show objects to partners merely for the purpose of experience-sharing.  Although children with autism are able to use gestures to request objects (instrumental gestures) or to engage in social action routines, they do not use gestures to share interest in objects…" (page 165).  There appears to be a significant deficit in emotional coordination.  As toddlers, they are less likely to combine smiles with eye contact or smile in response to smiles from their mothers.  Preschoolers with autism display happy, sad, angry, and neutral facial expressions as frequently but often during contextually incongruent situations.

"Children with autism are less engaged with and affected by other people's expressions of feeling (Hobson, 1993; McGee, Feldmen, & Chernin, 1991).  Furthermore, unlike matched controls, they do not use feelings to differentiate people from one another (Hobson, 1993; Ozonoff et al., 1991).  In studying adolescents, Bauminger and Kasari (2000) found that when teenagers with autism did make friendships, they were without the feelings of alliance or companionship that characterized typical friendships " (Gutstein and Whitney, 2002, page 166).  Individuals that continue these tendencies may be handicapped in intimate adult relationships.  An individual who does not habitually monitor and observe his or her partner's behaviors and feelings, would have difficulty responding to the partner's needs.  He or she would tend to inadequately nurture or support the partner's emotional, social, and practical needs.  Simple emotional mirroring, that is smiling when the other person smiles is lacking.  This would cause the partner to feel emotionally isolated.  Emotional mirroring and attention is a part of maintenance, which along with repair are important to continued healthy relationships.  Individuals in autism spectrum do not seem to see maintenance and repair in relationships as relevant.  Faith used to habitually "feed" Brody with affirmation of many types, including mirroring her interpretation of his feelings.  Unfortunately, Brody often seemed oblivious of Faith's attempts to nurture him.  As a result, not only did Brody not reciprocally offer much emotional sustenance to Faith, he did not give much acknowledgement or appreciation for Faith's efforts to mirror him.  When an interpersonal exchange becomes shaky, they lack strategies to bring it back on course.  They have difficulties altering communication to match the listener's needs despite understanding what he or she is thinking.  After various strategies to get Brody to "feed" her and appreciate her, Faith had started to give up.  She became resentful and increasingly negative.  Eventually, even mindblind Brody started noticing that she was treating him differently.  That however did not mean that he did anything differently.

"Adolescents and adults with AS seem oblivious to the lack of coordination in conversations and do not monitor their communication to ensure that it is correctly understood.  They do not attempt to repair communication; they do not work to ensure that they accurately receive other's communication; and they make no attempt to aid the listener when she or he communicates confusion, or to regulate their conversation to ensure that topics of interest match their social partner's ideas (Landa, 2000)" (Gutstein and Whitney, 2002, page 166).  They have problems appreciating differences in perspective of others when different from their own.  They have poor understanding of the listener's knowledge state.  Getting implied or extended thoughts beyond what is said is difficult.  There appears to be less responsiveness to others' distress.  The "absence of empathy and concern for other people's distress has been noted as a hallmark of autism (Sigman & Ruskin, 1999; Travis & Sigman, 1998) (Gutstein and Whitney, 2002, page 166).  As Brody noticed, he also focused on Faith treating him differently- specifically, being cold and spiteful.  He did not consider what Faith may be feeling to cause the change.  The consequence of partnering with someone who seems not to be attentive, does not get you, does not seem to care about your feelings, does not try to coordinate feelings with you, and seem to be in his or her own world leaves one much like the song "One is the loneliest number."

One is the loneliest number that you'll ever do

Two can be as bad as one

It's the loneliest number since the number one (lyrics Harry Nilsson 1969, performed by Three Dog Night)

Being alone and being lonely seems an inevitable consequence of not being in partnered relationship.  However, when one is a part of a couple such as Faith with Brody and still lacks intimacy, then two becomes the loneliest number.  Faith's expectation of partnership and mutual reciprocal nurturing from Brody makes their absence more devastating than she would have experienced with no such expectations as a single person.  

INTERACTIONS WITH INTIMATES/PEERS
While he had trouble with her lower levels of agitation, Brody could recognize when Faith was very upset.  Metaphorically, on a scale of 0 to 10, Brody was oblivious to Faith rising from calm and content (level 0) to beginning annoyance (levels 1-2-3) to mild to medium agitation (levels 4-5-6).  By then, Faith would not only be upset but also upset that Brody had not responded in any caring manner, and she would rise quickly into anger and rage (levels 7-8 and then levels 9-10).  Brody recognized the higher levels of anger and rage (7-10) as abrupt and unprecedented.  Having missed more subtle indication, he did not understand how she had gotten to such a level of anger.  He thought and sometimes verbalized, "Where the hell did that come from!?"  Upset himself and feeling targeted unjustly, he often responded with negativity of his own.  This seemed to be more proof of his unreasonable nature to Faith, rather what he experienced as a justifiable reaction to an unjustified action.  "How could he not know I was upset?!" Faith demanded.  "Why did she get so pissed so fast?!" he accused.

Other individuals often incorrectly attribute unexpected or agitated, including aggressive behavior from a person with Aspergers Syndrome to an assortment of negative causes.  Problematic habitual defense mechanisms may develop.  Kiriana Cowansage was not diagnosed with Asperger Syndrome until she was 19.  She handled teasing and harassment poorly and became confused about social interactions.  "The boys would provoke her- say, by stealing her pencils.  Over time, she began to suspect that any time a boy spoke to her it was to mock her.  She became defensively standoffish.  'I just wanted them not to talk to me, so I pulled together as much blunt sarcasm as I could and established myself as a weird, unfriendly girl'" (Flora, 2006, p.99).  It worked.  Despite being relatively attractive, at 24 years old, she had never had a boyfriend.  Although seen as strange with odd interests and behaviors as a child, adults never diagnosed her with Aspergers Syndrome. Individuals with histories of non-diagnosis and misdiagnosis with or without other co-existing issues are common.  Brody was misdiagnosed with ADHD as a young child and received inappropriate and largely ineffective interventions as a result.  Contributing to the misdiagnosis were dysfunctional family dynamics that prompted his distracted parents to hope for and seek a quick fix through psycho-medication.  Although Ritalin marginally helped with focus doing schoolwork, Brody suffered side effects (low appetite, limited weight gain, trouble sleeping) without his social and behavioral issues improving.  Misreading cues, rigidity, and poor relationships continued through his childhood.  He was able to intuitively and with some guidance from teachers and peers to become relatively successful with casual relationships.  It was only with the proper diagnosis of Aspergers Syndrome during couple therapy, could more appropriate support be instigated.

Children with Asperger Syndrome may have been extremely frustrating for parents before they encounter peers in daycare or school.  Parents of Aspergers Syndrome children similar to other overwhelmed parents may be vulnerable to losing perspective and restraint.  And may express their frustration over their children's behavior with harsh treatment or discipline.  Little (2003) says, "…rates of maternal verbal aggression (screaming and yelling, swearing, threatening to kick the child out, and calling the child names), were found to be higher than those reported by parents in a gallop poll survey of children in the general population… At the same time, rates of physical methods of discipline such as slapping, pinching and shaking the child, were also elevated… In this study of 411 mothers of children with AS, mothers of ten year olds reported using verbal or psychological aggression the most (33 times a year), and mothers of four year olds with AS reported using spanking on the bottom with a hand or slapping the most (14 times in the last year)" (p.136).  Harsh parenting presents models of aggression can enforce children's feelings of helplessness and vulnerability.  This may make any children, including Aspergers Syndrome children vulnerable to bullying and/or dysfunctional psychological compensations.  Presenting as odd, difficulties reading social cues make Aspergers Syndrome individuals and children negatively notable to others.  Peers in earlier years, however tend to be more accepting and forgiving of odd behavior.  Supportive adults in preschool and earlier elementary school years tend to be more effective enforcing inclusion and tolerance among young children.  Peer acceptance and adult management, however often breaks down when the single elementary teacher/classroom shifts to multiple teachers/classrooms in middle school.  Naïve about children with cruel intentions and about social interactions, children with Aspergers Syndrome may be easily manipulated into getting in trouble.

Highly judgmental, but insecure pre-teens needing to boost their fragile senses of self-esteem may quickly and mercilessly ridicule Aspergers Syndrome children for any oddities or missteps.  "…kids with AS were four times more likely to be bullied, twice as likely to be hit or kicked in their privates, and twice as likely to be hit by peers and siblings… also…children with AS and NLD experience high levels of peer shunning that seem to increase with age and peak in high school.  Middle school is a time when most children are trying to fit in and not be noticed as being 'different.'  Also, middle and high school are times when peers are more important and peer pressure influences much of what is considered 'socially appropriate behavior.'  Because children with AS stand out and are alone more often than their typical peers, they are at greater risk for bullying and shunning at a time when peer acceptance is most critical.  Peer shunning is the act of ignoring or excluding children.  Examples include children who sit alone at lunch, who are picked last for activities or games, and who are not invited to birthday parties or other common social events… peer victimizations and bullying of all kinds are pervasive among children diagnosed with AS," (Heinrichs and Myles, 2003, p.7).  Adolescence is the time when many individuals become interested in intimate romantic relationships.  Beyond the difficulties of developing peer friendships, the Aspergers Syndrome individual may be especially distraught about attempting deeper intimate bonds.  Flirting involves a multitude of social verbal and non-verbal cues in a complex social-cultural teen environment and more adult environments.  This can be sabotaged by misinterpretations and miscommunications.  Faith flirted with Brody… she invited him to be playful by being playful.  Playful interactions or flirting tend to be enduring behaviors of happy and functional couples that sustain the relationship.  Brody did not play particularly well with others and did not particularly understand, accept, and reciprocate play invitations well with Faith.  Their initial relationship progressed primarily on Faith's initiation and prompting.  And, deteriorated as she lost interest in maintaining it as she felt more and more by herself.

THEORY OF MIND & RELATIONSHIP CONSEQUENCES
Theory of Mind refers to a person's ability to intuit or guess what the other person is thinking, feeling, or experiencing.  With a good Theory of Mind, a person makes reasonable accurate guesses about the other person's underlying intentions and motivations.  Theory of Mind is required to understand the behaviors of others or characters in some tale.  The person speaking uses his or her Theory of Mind skills to anticipate the other person's perspective and knowledge to selectively organize and convey information.  By anticipating what the listener already knows, what is new, and what he or she needs to know, the speaker is better able to convey the message so that it will be received as the speaker intends.  A person with a poor Theory of Mind would having difficulty speaking to or responding to the other person's perspective.  The listener may be confused or bored if the speaker gives information outside of the listener's expectations.  "The story-telling task therefore gives us an important window into how well a speaker can keep track of information for a listener, how well they can edit information for a listener,—in short, how skilled the speaker is employing a ToM" (Colle et al., 2008, page 28).  When Brody told Faith about something- that is, a story, he often droned on about details that did not seem relevant to her.  She gave cues that she was not getting his story, including being mystified about his story, not being interested, and wishing instead to share her interest about the Great Wall of China as opposed to the Great Firewall of China.  He was often oblivious to her gestures and facial cues showing her mood and interest- that is, disinterest.  Individuals with Aspergers Syndrome often have social problems, very narrow interests, or repetitious behavior, while having no significant issues with delays in language or cognitive development.  However, they may show subtle communication characteristics with excessively formal or pedantic word choices.  The listener becomes the non-participating passive audience as the Aspergian's communication becomes a monologue, presented with emphatic emphasis that can seem rude and pushy.  Brody endless description of the Chinese Firewall was a typical monologue that Faith had endured many times before.

"The intensity of the single focus on one narrow topic of conversation may also reflect their cognitive style of strong 'systemizing' (Baron-Cohen, 2002, 2006), needing to focus on the small details of an argument and pursue it to its logical conclusions in order to achieve an understanding of the topic as a web or system of facts.  Again, in not being able to judge the inappropriateness of staying on one topic for too long, or going into such minutiae for too long, the speaker with AS reveals their difficulties with ToM, or what is today seen as part of a wider difficulty with empathy (Baron-Cohen, 2002)" (Colle et al., 2008, page 29) shift topic (page 30).  Individuals with Aspergers Syndrome also may have problems sustaining the current conversation topic, by interjecting comments that are not relevant or by not adding relevant information to extend the conversation.  They may have trouble judging if the other person wants to keep on the same topic or missing the cues that they want to or not.  Individuals with Aspergers Syndrome preferred using "simple and unlinked sentences, without taking into account the relation between a specific event with what had happened before."  They used terms referencing temporal expressions less often.  "These results suggest an impairment in the ability to establish links between particular episodes with more global themes, highlighting difficulties in referential ability" (Colle et al., 2008, page 37-38).  Individuals with autism can label emotions but do not comprehend the thoughts and cognitive state underlying them.  Understanding metaphor, inferring what is implied in context, and getting intentional spoken inferences are all challenging.  Emotions can be divided into situation-based emotions such as sadness and happiness versus belief-based emotions such as surprise.  Based on the Theory of Mind concepts, people with autism have more problems recognizing belief-based emotions versus situation-based emotions (Golan et al., 2006, page 170).  On the other hand, accurate Theory of Mind skills facilitate understanding such emotions and thus, communicating in ways that resonate with the listener.  "the HFA/AS group performed appropriately in introducing and reintroducing a character in the narrative…, but showed a subtle but significant deficit when the listener's needs determined the use of pronouns, to maintain reference to a character, and in their use of temporal expressions. This resulted in the use of pronouns whose referents were ambiguous (Colle et al., 2008, page 38-39).

The characteristics of Aspergers Syndrome predict poorer functioning making and maintaining emotional connections.  They subsequently have corresponding poorer functioning in making and maintaining peer and intimate relationships.  "…although many adults with AS/HFA do have friendships, compared with people in the normal population, their relationships are less close, less empathic, less supportive, and less important to the individual.  In addition, adults with AS/HFA like and are interested in people to a lesser extent than control adults, and they are less likely to enjoy interaction with others for its own sake.  The more autistic traits an affected adult has, as measured by the AQ (autistic quotient), the lower their FQ (friendship quotient) score.  The FQ also correlates with the EQ (emotional quotient) so that affected adults who report greater levels of empathy also report having friendships that are more similar to the normal population (i.e., a higher FQ score)… A high FQ score is achieved by respondents who report enjoying close, empathic supportive friendships; who like and are interested in people; who enjoy interaction with others for its own sake; and for whom friendships are important.  In the general population, women scored significantly higher than men…" (Baron-Cohen and Wheelwright, 2003, page 513).  Faith qualified as more desirous of close, emphatic, and supportive relationships in general, and of course with her husband Brody.  Initially, she thought that Brody's lesser behavior, interest, and investment in a closer relationship was emblematic of Brody being a guy.  After all, weren't guys less overtly intimate and emotionally expressive?  Over time however, he was too much of a guy if that meant being hardly interested and minimally active in meeting her emotional needs.  Faith did not know his extreme reticence was a consequence of Aspergers Syndrome until couple therapy.

PROBLEMATIC SOCIAL COMPENSATIONS
Undiagnosed and unsupported Aspergers Syndrome behaviors accumulate social and emotional damages from negative treatment from peers and adults that often become explosive for individuals in middle school.  Intervention is challenging because of normal but difficult pre-adolescent developmental emotional, psychological, social, and cultural storms.  Girls are usually more socially adept at handling social interactions by auto-responding to triggers.  They like the killer android in the "Terminator" movie, who when deciding how to respond to a human inquiry, chooses responses from a database menu, (Cameron, 1984).  Girls often get more and specific training about how to respond given different situations.  However, they may find hiding their Asperger issues in middle school much more overwhelming than during elementary school.  A New York Times article (Bazelon, 2007) quoted, Catherine Lord, a veteran autism researcher.  "The girls often have the potential to really develop relationships…But by middle school, a subset of them is literally dumbstruck by anxiety.  They do things like bursting into tears or lashing out in school, which make them very conspicuous.  Their behavior really doesn't jibe with what's expected of girls. And that makes their lives very hard".  Lord notes the rising level of social interaction compared to earlier years that comes in middle school.  "Girls' networks become intricate and demanding, and friendships often hinge on attention to feelings and lots of rapid and nuanced communication… No matter how much they want to connect, autistic girls are not good at empathy and conversation, and they find themselves locked out, seemingly even more than boys do."

On the other hand, since female socialization often tends to emphasize greater self-awareness and attention to how one affects others, females with less severe Aspergers Syndrome characteristics may have more successfully compensated.  Males with Aspergers Syndrome who as boys and men are generally less socialized to be self-aware and cognizant of their social impact on others may tend to have characteristics exacerbated by cultural expectations and guidance.  The strong silent stoic male model may merge with Aspergers Syndrome to result in a functional deficit in empathy.  Although individuals with Aspergers Syndrome have difficulty interpreting and anticipating other's actions, feelings, thoughts, and motivations, they ordinarily do not necessary wish them any negativity.  When told that their behavior (or lack of) or words were harmful (dismissive, intrusive, or disrespectful), they usually feel badly for being hurtful.  On their own, they may not see how they caused another's hurt.  Even though, they may also have difficulty seeing how they could have behaved differently, they still regret the harm caused.  "From this we can conclude that people with AS/HFA are not like unfeeling psychopaths.  Rather, psychopaths might be expected to show the opposite profile- being able to judge and predict how another person might feel, even if they have little concern about that person's emotion (Blair, 1995; Blair, Jones, Clark, & Smith, 1997). (Baron-Cohen and Wheelwright, 2004, 169).  Individuals with Aspergers Syndrome who fail to respond as socially expected to cues risk being labeled as knowing and not caring… of being hurtful purposefully.  Females irrespective of diagnoses are culturally more encouraged to notice, to care, and to act.  Females in general recognize emotions in faces better than males.  Males with Aspergers Syndrome have higher vocal comprehension scores than facial comprehension scores.  They may use the higher skill as compensation to guess about emotions (Golan et al., 2006, page 178-79).  They do poorer in general on emotional intelligence than females.  "…more than three times as many men (14%) as women (4%) scored in the 'AS/HFA range' (i.e., equal to or fewer than 30 points), whereas more than three times as many women (9.5%) as men (2.8%) scored in the "superempathic range" (i.e., equal to or more than 62 points)" (Baron-Cohen and Wheelwright, 2004, page 170).  Differences in socialization and cultural training for males versus females probably contribute to this statistical difference.

However, differences have been attributed to "the extreme male brain (EMB) theory of autism (Asperger, 1944; Baron-Cohen, 2002, 2003; Baron-Cohen & Hammer, 1997).  The EMB theory recognizes two psychological dimensions: 'empathizing' (E) and 'systemizing' (S).  Empathizing is the drive to identify another's mental state and to respond with an appropriate emotion to this.  Systemizing is the drive to analyze a system in terms of its underlying lawful regularities and to construct systems using such lawful regularities. The male brain is defined as individuals in whom S > E, and the female brain is defined by the converse psychometric profile (E > S).  The EMB theory predicts that individuals on the autistic spectrum will show an exaggerated male profile (S >> E).  The results of the EQ study above are consistent with this theory, as are a series of other studies (Baron-Cohen et al., 1997; Baron-Cohen, O'Riordan, Jones, Stone, & Plaisted, 1999; Baron-Cohen, Wheelwright, Scahill, Lawson, & Spong, 2001a).  This theory may have implications for the marked sex ratio in AS (8m:1f) (Wing, 1981)" (Baron-Cohen and Wheelwright, 2004, page 170).

Males arguably are not encouraged to be introspective as are females, which may intensify another characteristic of Aspergers Syndrome.  Individuals with Aspergers Syndrome may have problems with autobiographical memory.  Autobiographical memory holds information about oneself and experienced events.  Such memories provide essential experiences to facilitate social intimacy and problem-solving.  "…it is an important predictor of healthy psychological functioning and autobiographical memory deficits have been associated with a range of clinical conditions, in particular depression and parasuicide (Williams, 1996) (Goddard et al, 2007, page 291).  Memory of individuals with Aspergers Syndrome may more associated with noetic awareness (awareness associated with timeless facts), while having more problems with autonoetic awareness where the context of the memory is also remembered.  "…the specific autobiographical memory system in Asperger syndrome may be impaired because specific retrieval is, in essence, memory with self-awareness" (page 292).  A person such as Brody has proficient memory of facts and details, but poor memory of personal specific experiences- in particular, emotional memories and emotional impressions of others.  When Faith or the therapist ask "What were you feeling and thinking?" he often is honestly stumped for an answer.  "What do you think Faith was feeling?" is even more difficult to answer.  Since specific personal memories are more layered and nuanced with cues, they offer greater guidance for handling new emotional and social situations.  "Social problem-solving difficulties have been demonstrated in children and adolescents with Asperger syndrome particularly with respect to the generation of socially appropriate solutions (Channon Charman, Heap, Crawford, & Rios, 2001)" (page 292).  Social problem-solving deficits may decrease with maturity if compensating skills are acquired.  However, poor compensations may include isolating, social withdrawal and avoidance, arrogance (including narcissism), or argumentative styles that harm adult relationships.  Difficulty in using autobiographical memory for social problem-solving may not be a problem in accessing memory after the fact, but from problems identifying cogent aspects of problems in the original social-emotional context.  "…social deficits in Asperger syndrome are due to a more general inability to see the relevance of knowledge to particular problems rather than being a result of incompetence" (page 298).  The therapist can ask a rhetorical question, "Didn't you know that Faith was upset?"  The questions implies that Brody should have known that Faith was upset.  However Brody, who has not only missed the therapist's implication, but having missed Faith's emotions in the first place, responds with a bland, "No."  The answer "No" is not a sarcastic response, but a honest reply.  Brody did not know.  He did not and does not get it.

If an individual is not aware of how his or her partner's Aspergers Syndrome complicates reading social cues and fundamentally alters reciprocal social interactions, he or she often concludes that the partner does not care and is not invested in the relationship.  If the therapist conveys to the couple an accurate diagnosis of Aspergers Syndrome, it enables the Aspergian individual to better understand his or her challenges and directs him or her to make appropriate adaptations.  For the non-Aspergian partner, diagnosis gives him or her explanation for previously dismissive and hurtful communications and responses.  This offers hope that the syndrome has harmed the relationship rather than the person does not care, love, or respect him or her.  The greater challenge may be for the therapist to convince the Aspergian individual of the relevance of the diagnosis.  Adults who have endured years of compensating for Aspergian challenges, may find it too uncomfortable to accept what they experience as another diagnosis of weirdness- no matter how clinically it may sound.  Interventions and support to compensate for Aspergers Syndrome challenges that was offered when the individual was younger may not have been fully embraced.  Social skills feedback may have been ineffective when taught in isolation.  Without a clear motivation based on the context of social interactions, instruction targeting improved eye contact, joint attention, imitative play, and so forth may only result in temporary changes.  Improvement may be only in isolated situations- specifically in a teacher, parent, or other adult structured and guided exercise.  The skills may not be generalized to the more fluid and demanding social situations with peers, much less with an intimate partner.  Rewards from success in contrived exercises do not necessarily translate to seeking and gaining inherent pleasure and satisfaction in normal daily interactions with others.  

Repeated failures attempting to gain rewards from interplay with peers, individuals with Aspergers Syndrome may seek out other means to gain satisfaction.  Rather than motivated to seek and improve social skills, such individuals may become motivated to avoid disappointing and hurtful social experiences.  They may become ever more socially dysfunctional and/or function exclusive of social relationships.  "As the child with AS gets older, he or she misses out on more and more rewards from experience-sharing and obtains more and more from other means.  A sense of competence and mastery is one of the most important motivations to any child and especially to a child who is already experiencing difficulties with mastery (Kasari, Sigman, Baumgartner, & Stipek, 1993)" (Gutstein and Whitney, 2002, page 166).  In adulthood and attempting an intimate partnership relationship, the individual with Aspergers Syndrome may be challenged, but yet deeply motivated to become competent in social skills heretofore discouraging and dis-inspiring.  The opportunity to be intimately fulfilled and the threat of the couplehood disintegrating may finally provide motivation for the individual to fully engage in addressing his or her Aspergers issues.  The therapist may frame accepting and dealing with previously unaddressed (even denied) Aspergers issues as essential or the key to couple's resolutions.  Using the couple's crisis as an opportunity to address Aspergers is appropriate since the Aspergers Syndrome crisis precipitated or is foundational to the couple's dysfunction.

Couple therapy with an Aspergian partner is further challenged by his or her difficulty with experience-sharing.  Experiencing-sharing interactions create bonding between individuals.  They are based partly on their unpredictability and unique qualities.  Individuals with Aspergers Syndrome along with others who suffer anxiety from anticipated harm from unpredictability, tend to prefer rote responses which follow a prescribed and inflexible script.  Experience-sharing however requires attention to the immediate words and behaviors of the social partner and anticipation of what may be done or said next.  Successful experience-sharing and relationship development require skill at social referencing.  Social referencing is when an individual seeks the emotional reactions of the social other in order to determine his or her subsequent choices of words and behavior. The "ongoing actions and communication of the social partner become primary reference points in determining his or her subsequent actions.  Hobson pointed out that by age 1, children have already learned to seek out their parents' interpretation of an ambiguous situation.  As typical children develop, they recognize the importance of understanding numerous areas of their relationships with their partners, such as their partner's perceptions, ideas, plans, dreams, and inner (as opposed to outer) feelings.  Hand in hand with this increasing motivation to reference, the child develops more sophisticated observation and communication skills to achieve a greater ability to evaluate the reactions and potential future responses of social partners" (Gutstein and Whitney, 2002, page 167).

Unfortunately, individuals with Aspergers Syndrome have poor social referencing skills due their difficulty recognizing social cues.  The therapist encounters the couple after possibly years of inadequate experience-sharing and the subsequent damage to the relationship.  Common therapeutic interventions offered to the couple may prove inadequate and frustrate both the therapist and the partners.  The therapist needs to be aware of interventions and feedback that presume normal social referencing skills and accurate empathetic interpretations of the other's feelings and thoughts.  "How do you feel about your partner's feelings (thoughts or actions)?"  This simple query may anticipate incorrectly that a partner with Aspergers Syndrome is intuitively aware of the other partner's feelings, thoughts, or actions.  With an inaccurate assumption, the Aspergian partner would possibly (perhaps, probably) respond in a fashion that appears insensitive, dismissive, or disrespectful of such feelings or thoughts.  Both the therapist and the non-Aspergian partner may label him or her as insensitive, dismissive, or disrespectful!  Perhaps, a narcissist.  The relationship between the partners remains negative and the therapist's assessment of the Aspergian partner turns negative.  Therapeutic work to get the Aspergian partner to validate his or her partner's feelings and thoughts- a fundamental goal of communication-oriented therapy among other orientations, may be frustrated.  Not only frustrating but also ill-directed.  The Aspergian partner cannot validate what he or she does not get or perceive accurately in the first place.  The therapist should check with the Aspergian partner what he or she perceives or interprets prior to any judgment or opinion about them.  In addition, the therapist should check whether the partner has assumed that the Aspergian partner has interpreted or perceived him or her correctly.  The partner may be deeply hurt to somewhat amused based on the difference between assuming that the Aspergian partner's response is based on an accurate versus inaccurate interpretation.  The response is seen as ranging from cruel to simply misguided.  The intentionality of the Aspergian partner's response becomes the focus of therapy for the time being.  If his or her intentions are deemed not malicious or uncaring, then therapy shifts to problem-solving and communication work with pointed consideration of Aspergers Syndrome complications.

Couple therapy is further complicated by the Aspergian partner's limited skills and experience with co-regulation.  Co-regulation is the process where individuals constantly change their behaviors relative to the current, continued, and anticipated behaviors of others.  Interactions are not based on scripts but in a mutual regulation of actions based on constantly referencing and alterations to ongoing changes in the social realm.  Co-regulation with social referencing serves to allay confusing cues and negative emotions and improve alignment of purposeful mutual action.  Interactions and the relationship would be more enjoyable, fulfilling, and stable as a result.  The interactions are less likely to be perfunctory or rigid and missing individuals' needs (Gutstein and Whitney, 2002, page 167). With co-regulation and social referencing, the relationship is more secure and satisfying.  The therapist should not assume that the Aspergian partner adequately does social referencing and participates in co-regulation.  The therapist may promote Brody to engage in social referencing.  As the therapist prompts Brody's awareness of Faith's actions in co-regulation, Brody can be guided to experiment with his own attempts at co-regulation.  "What does that mean?   What do you want?" and "What did that mean?  What are you supposed to do?"

Brody had not done what Faith expected to maintain their relationship, but not because he did not care.  He was negligent because he did not know how important it was to her to be sustained in the relationship.  The task of couple therapy would be to impress upon Brody the requirement of his attention to and activity to step beyond his Aspergers Syndrome restrictions.  This comes after identification of the diagnosis and getting Brody to accept it.  Rather than trying to get Brody to do what is fundamentally difficult, the therapist should enter the "door" that is available- the Aspergian thinking process.  As opposed to only directing him to Faith's emotional and mental states of mind in an attempt to facilitate empathy, the therapist may find directing him to a more mentalistic orientation that is more productive (and therapeutic).  The therapist can assert that the "problem" of the relationship is the lack of important behaviors on his part… his insufficient role in co-regulation.  The "solution" to the problem becomes learning and consistently practicing specific behaviors.  "This is what Faith needs.  This is what you need to do.  This is how you can make her happy.  This is how you can be a good husband.  You didn't know this before.  Now you do.  So do it."

Investment and caring remain the foundation of the relationship, which would hopefully motivate Brody to extend beyond himself.  If Brody questions the validity of Faith's needs, the therapist should not allow him/herself to be drawn into an argument.  The therapist should assert, "That is just how she is.  For the marriage to work, you need to accept it.  She has to accept how you are too.  For good or bad, it is how she is made up.  This how you are made up.  But that is not the same as you or her cannot do some things differently.  Both of you need to change or adapt behavior for the other to make the marriage work.  Faith cares enough about you to accept you fundamentally.  She has adapted her behavior for you.  It's your job to do the same for her.  Do you care for her enough to do this for her… even if it doesn't make sense to you?  That is how the problems will be fixed."  As with the dealing with a learning disability or ADHD diagnosis in the couple, the therapist may need to take a strong directive stance.  The therapist should assert that the Aspergian partner accept the requirement.  This may require significant skillful and time-consuming therapeutic work depending on how defensive the Aspergian partner may be.  With his or her acceptance, therapy proceeds to coaching joint attention, experience-sharing, social referencing, recognition of non-verbal cues, and so forth.  The focus seems to be solely on Brody for what he needs to do that has been lacking and contributing to relationship problems.  However, there should be also some focus on Faith for what she has tended to do that has sustained the relationship.  For example:

When Brody starts talking about his magazine while Faith is talking about her magazine, Brody is to notice that she seems distressed and looks distracted- she looks away several times. Brody should ask her, "Were you finished talking about your magazine?" and then offer to listen to what she wanted to share before talking about his magazine.

While talking about her article, Faith notices that Brody seems a bit excited and is handling his magazine.  Faith says, "Let me tell you about my article and then, you tell me about your article.  OK?" She says this while pointing at his magazine and also touching him on the arm.  

While telling Faith about the Great Firewall of China, Brody notices that Faith tips her head a little to the side along with a slight frown and her mouth parting her.  He is to consider that she may not be understanding him and ask, "Am I making sense to you?  Should I explain it differently?  What don't you understand?"

Gutstein and Whitney (2002, page 167) present six key factors from their review of the typical development of experience-sharing relationships.  The six factors slightly adapted offer guidance to the couples therapist.  Establishing willing "students" is an intrinsic requirement to implementing these factors.

1. teaching skills in a developmental, step-wise progression, where rudimentary skills form the foundation for their more sophisticated counterparts;

2. initially providing instruction from more competent individuals, who act as both "guides" and "participants";

3. developing simple, ritualized frameworks that allow for a degree of predictability without limiting the potential introduction of novelty and variation;

4. initially working in a simple, nondistracting environment;

5. spotlighting and amplifying the important actions and communication of "coaches" so that they are easier to read by the novice learner; and

6. moving gradually from the therapist as guide to evenly matched partners and from simpler to more complex settings.

The therapist needs to be knowledgeable about skills deficits associated with Aspergers Syndrome in order to venture the psycho-educational aspect of therapy.  Both partners may require significant education not just about Aspergers Syndrome intellectually, but also how it manifests in their relationship.  In the couples dynamic, both the therapist and the non-Aspergian partner can be participant-guides if the Aspergian partner becomes willing to empower them with the role.  Gaining the Aspergian partner's assent to be guided by the therapist, and subsequently by his or her partner is a critical early goal of therapy.  A person such as Brody may find this difficult to accept.  Having experienced negative treatment over the course of his life, he is likely to be defensive about opening himself to what he experiences as more critical assaults on his worth.  If he is stuck in a narcissistic compensation, the therapist would need to adroitly and skillfully use knowledge, experience, and expertise get Brody to defer to him.  If and when the therapist achieves the expert status necessary to engage the narcissism (for discussion on this therapeutic strategy see "Scorpion in the Bed, The Narcissist in Couples and Couples Therapy" by the author- Smashwords.com, 2013), he or she can proceed to confer similar status to Faith.  The challenge of therapy is to achieve this while managing Brody's instinct to resist Faith's "criticism" and take it instead as supportive feedback.  The therapist must guide and structure Faith's communication to be honest and direct while managing and minimizing inflammation of Brody's hypersensitivity and hypervigilance against anticipated further esteem attacks.

The therapist may use the therapy session for the couple to establish and practice ritualized interactions between the partners.  As a "referee" or "guide," the therapist provides greater predictability and security in the environment of the session than can be achieved at home.  The therapist interacts, interrupts, guides, and gives feedback highlight and reinforce positive choices and actions and to mitigate and alter poor choices and actions.  It is important to remember that the therapist's interactions or relationship with the Aspergian partner is practice for the Aspergian partner and also a model in for the non-Aspergian partner to emulate.  "Brody, you got it that time.  You saw… guessed what she felt and gave her what she wanted."  Or, "I saw you turn away.  That seems to be you not liking something.  Is that correct?  What did you think she meant?"  In particular, the therapist can point out misinterpretations and focus the Aspergian partner on relevant cues that would otherwise missed.  The therapist can point out the partner's non-verbal or verbally implicit attempts to request particular behaviors and responses.  

"Brody, look at Faith's face.  What did that expression mean?  What do you think she felt or wanted?"  Or, "Faith, did Brody get it right?  What did he do that showed you that he got it?"  In the process of therapy, if the communication and understanding between the partners improves, so should their trust in each other increase.  Weekly reports of arguments and problems should gradually start to include some reports of arguments and problems that did not completely deteriorate.  Hopefully, the will eventually be reports of arguments and problems precluded because of adaptations attempted and found effective.  With gradual improvement, Brody will be more likely to trust Faith's good intentions and the integrity of her feedback.  Likewise, Faith may be more able to trust that Brody can and will verbalize his own process, including his confusion and uncertainty about what she is communicating and desiring.  Brody can become an active agent in improving the couple's dynamics.  They become more evenly matched as partners.  Equally invested and equally empowered, they both have responsibility to improve things.  Previously, Brody was the IP (identified patient) or messed up one, while Faith was the "good" long-suffering partner.  

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
phone: (510) 614-5641
fax: (510) 889-6553
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