Information about the author:
Dr. Annelies Spek is clinical psychologist and senior researcher at the adult autism center in the southof the Netherlands (Eindhoven). Her Ph D thesis was entitled: cognitive profiles of adults with high functioning autism (HFA) or Asperger syndrome. Now she examines the effects of treatment in adults with autism. She also gives lectures about diagnosis and treatment in adults with autism.
Furthermore, she gives mindfulness training to adults with autism and she developed a training program for clinician s (who work with adults with autism) on this subject. For more information about (mindfulness in) adults with autism: here- mail address is firstname.lastname@example.org
The original book ‘Mindfulness in adults with autism’, has not been translated in English yet. If you would like to be informed about this in the future, send me an email. If you have any ideas that might help to have the book translated in English, please contact me!
Autism is a lifelong developmental disorder that affects functioning in multiple areas. Recent studies show that autism is often accompanied by other psychiatric symptoms, including depression, anxiety, hyperactivity, inattention and distress in general. Evidence suggests that depression is the most common psychiatric disorder seen in autism (Ghaziuddin et al., 2002). Especially adults with relatively high cognitive ability seem at risk for developing symptoms of depression, possibly because they are more aware of expectations of the outside world and their inability to meet those.
Symptoms of depression in adults with autism seem different than in other individuals, ranging from irritability to an increase in difficulty with change and sensitivity for sensory stimuli (Ghaziuddin et al., 2002). An important aspect of depression and distress in people with autism is the tendency to ruminate. This can be described as a drive to think repetitively and experiencing difficulty to let thoughts go. For instance, adults with autism often lay awake at night, pondering about the events of the day and analyzing those in detail. The tendency of people with autism to ruminate appears related to the detailed information processing style that characterizes autism.
Treatment in autism
Various interventions have been developed to alleviate distress and co morbid symptoms in autism, although evidence for their efficacy is still limited. Most of these interventions aim to adapt the environment to meet the needs of the person with autism. Despite the importance of such interventions, it has become increasingly clear that there is a need for therapies that offer tools that people with autism can use themselves to actively tackle problem situations and reduce distress. Especially the high functioning group may be able to acquire and use self-help techniques they can use in daily life.
Recently, cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) have been modified for high-functioning individuals with autism. Both therapies aim to reduce co morbid symptoms in autism and alleviate distress in general. In CBT, dysfunctional thoughts and emotions are analyzed and modified into more functional thoughts and emotions. Recent preliminary studies in autism show promising results, especially for symptoms of anxiety and depression (Weiss & Lunsky, 2010). However, generalizability of the CBT skills seems limited. Furthermore, CBT appears challenging for individuals with autism because it requires analyzing and talking about thoughts and feelings, which calls upon communication and theory of mind skills that are usually impaired in autism. This stresses the need to develop and examine more interventions for people with autism.
In MBSR, one learns to regulate attention in order to stay in the present moment and be less hindered by ruminative thoughts and emotions. MBSR has recently been modified for people with autism, taking into account their information processing characteristics. A clear advantage of this intervention is that it requires few theory of mind and communication skills since thoughts and emotions are not analyzed. During the MBSR training, meditations skills are taught, which the individual can use him/herself in the home situation in order to reduce rumination and symptoms of distress. This seems to induce generalizability to daily life situations. A disadvantage of MBSR is that participants need to practice at home for half an hour to an hour a day during the training. For the individuals with ASD who are able to spend this amount of time, MBSR seems an effective treatment to reduce symptoms of anxiety, distress and rumination (Spek et al., submitted).
In the following paragraphs we will elaborate on the theoretical and practical elements of an MBSR group intervention for adults with ASD. Finally, we will discuss the effects of MBSR in these groups, as they appeared in a randomized controlled trial and in clinical practice.
Theoretical elements of MBSR in adults with ASD
In the MBSR training module, the concepts ‘doing-mode’ and ‘being-mode’ are central. Both modes are described as conditions of the brain: When the brain is in a doing-mode, it is thinking and actively seeking solutions for problems. The brain is than focussed on achievement and outcome. However, when there is nothing you can do or say to solve the problem, it is not useful and often even frustrating to keep searching for solutions (ruminating). In these situations it seems more healthy to stop searching and accept the situation how it is. This state of mind in can be described as a being-mode: not wishing to change, not worrying about goals in the future, but experiencing what is present in the moment. Often, participants in the MBSR group ask if it is possible to do something when you are in the being-mode. Than we explain that you can ride a bike in the being-mode if you pay attention to the present moment, for example the wind in your hair or feeling your muscles. If you ride the bike in the doing-mode, you are not aware of the present moment, but instead thinking about work or other things that are in the past or future.
While the doing-mode can be very useful when trying to achieve something, people with autism often stay in the doing-mode when this is not functional. For instance, when lying in bed and wanting to fall asleep, or when there is a problem that cannot be solved, people with autism often keep pondering. In these situations they often feel the urge to ‘stop thinking’, but are unable to do so. For many people with autism, it is very difficult to create a peaceful or still mind. During the MBSR training, the participants learn to reach more control over the focus of the mind, for instance by actively direction attention to the breath or the parts of the body. When the attention is directed to the breath or body, it can feel as if the mind is more at peace, because the attention is away from thoughts and actions, towards a more peaceful focus and thus into the being-mode. This can help by stopping the thought cycle and fall asleep. When people with ASD learn to influence the mode of the brain, it helps them to actively create a more peaceful mind, by shifting from the doing-mode to the being-mode.
Another key aspect of the MBSR training for people with ASD is acceptance of the situation as it is. Many people loose energy by trying to change things that can not be changed. Accepting often requires less energy than keep fighting for something that is not realistic. This is always a theme MBSR training and it is recognizable for many adults with ASD, in various areas of their life.
MBSR can be taught in a group, but also individually, by using the book ‘Mindfulness in adults with ASD’. This book has so far been published in Dutch and German, an English translation is yet to come.
During the MBSR training, different meditation techniques are taught. These techniques are practiced in daily life situations (for instance at home or at work), accompanied by an audio file. The meditations are modified to the information processing style of autism, for example by avoiding words or sentence that are unclear or that require imagination skills. An example is that in regular mindfulness, participants are asked to breath in and let the breath go to the toes. In our try-out MBSR training, a man with autism remarked, while pointing at stomach: ‘I can’t do that because my lungs end here’. Based on those and other experiences of the try-out group, we modified the text of the meditations (with regard to the example above: ‘breath in and perhaps you can feel the breath go down’).
The meditation techniques can be practiced lying down, sitting, walking or in any other way that feels comfortable. The length of the meditations vary between five and forty minutes, which is dependent on what fits best with the individuals needs and opportunities. Eventually, during the MBSR training the participants explore which meditation techniques are helpful for them and in which situations they experience most benefit. After the nine-week mindfulness training, each individual writes a plan of which meditations they want to integrate in their daily life and when and where to execute them. Often, they choose a person in their environment who helps them to keep practicing mindfulness.
Treatment effects of MBSR in autism.
MBSR in ASD has been studied in adolescents and adults. Two studies were performed in adolescents with either high-functioning autism or Asperger syndrome and results were promising (Singh et al., 2011a,b). In these intervention studies, the adolescents were taught to shift their attention from their emotion (anger, frustration), to the soles of their feet. The results showed a decrease in aggression.
In our study, 42 adults with ASD were randomly assigned into a 9-week MBSR training or a wait-list control group. The results showed a significant reduction in depression, anxiety and rumination in the group who received the MBSR training, as opposed to the control group. Furthermore, positive affect increased and negative affect decreased in the intervention group, but not in the control group. We concluded that adults with ASD can acquire meditation skills and generalize these into their private life in a way that reduces distress and improves wellbeing (Spek et al., submitted). Besides this scientific trial, we also asked the participants in person if and how the MBSR group training helped them. Firstly, we noticed that on average, each group (with 10 to 12 participants) contained one person who reported no benefit from MBSR. Although more research is necessary to examine predictors of benefit from MBSR in this group, an interesting suggestion came from one of adults with ASD who participated in an MBSR group. She hypothesized that treatment benefit might be related to the ability to feel the body; If one can not feel any bodily sensations, it may be difficult to focus on the body or the breath, which might reduce the ability to benefit from MBSR.
When looking at the participants who did report positive effects from MBSR, the most mentioned improvement was the ability to fall asleep more easily, often by direction attention to the body (body scan) or to the breath. Secondly, many participants mentioned that MBSR helped them to let go of thoughts and be less hindered by ruminative thoughts, by directing attention to another focus. Most of these participants practiced the thinking meditation (focusing on thoughts going by) or the breathing meditation, mostly during the day, in order to stop ruminating and creating a moment of rest in their mind. This helped them to reduce distress in challenging situations, for instance at work. Thirdly, participants mentioned that MBSR enabled them to be more kind and accepting toward themselves, some realized that they set the bar too high, which inevitably leads to failure and distress.
Concluding, MBSR seems an effective intervention for reducing co morbid symptoms of depression, anxiety and distress in general in high functioning adults with ASD. Furthermore, they are able to actively acquire techniques that can help them gaining more control over their wellbeing.
It is important to also mention that in some situations, MBSR is not advised. For instance when expecting large changes in life, people may not have the energy for the MBSR training, since it requires daily home practice. Furthermore, acute psychiatric conditions (psychosis or severe depression) are contraindications for following MBSR and require other interventions before MBSR should be considered.
Ghaziuddin, M., Ghaziuddin, N, & Greden, J. (2002). Depression in persons with autism: Implications
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Singh, N.N., Lancioni, G.E., Manikam, R., Winton, A.S.W., Singh, A.N.A., Singh, J., & Singh,
A.D.A. (2011) A mindfulness-based strategy for self-management of aggressive behavior in adolescents with autism. Research in Autism Spectrum Disorders, 5, 1153-1158.
Singh, N.N., Lancioni, G.E., Singh, A.D.A., Winton, A.S.W., Singh, A.N.A., & Singh, J.
(2011). Adolescents with Asperger syndrome can use a mindfulness-based strategy to control their aggressive behavior. Research in Autism Spectrum Disorders, 5, 1103-1109.
Spek, A.A., Van Ham, N., & Nyklíček, I. Mindfulness-based stress reduction in adults with an autism
spectrum disorder, a randomized controlled trial. Submitted.
Weiss, J.A., & Lunsky, Y. (2010). Group cognitive behaviour therapy for adults with Asperger
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