PDA Strategies and Person Centred Counselling

Before starting, I would like to clearly point out that, while I believe person centred counselling is a great fit for PDA needs, the therapy will not be effective if a PDAer, young or old, is directed to enter into it. The saying goes, you can take a horse to water, but you can't make it drink, and for PDAers, if you try taking us to water/counselling we'll likely respond by bolting as far away from it as we can!

Definitions:

Person centred counselling, as described by Counselling Directory is:

"A humanistic approach that deals with the ways in which individuals perceive themselves consciously, rather than how a counsellor can interpret their unconscious thoughts or ideas. ... The therapist in this approach works to understand an individual’s experience from their perspective. The therapist must positively value the client as a person in all aspects of their humanity, while aiming to be open and genuine. This is vital in helping the client feel accepted, and better able to understand their own feelings. The approach can help the client to reconnect with their inner values and sense of self-worth, thus enabling them to find their own way to move forward and progress."

PDA (pathological demand avoidance), which is classed as an autism spectrum condition, features:

• Hardwired aversion to anything perceived as a demand (including hints and expectations)
• Strong need for personal control
• Judging people, rules, etc, on merit as opposed to arbitrary authority
• People-focus (which may become obsessive)
• Drive to socially mimic and mask
• Propensity for fantasy and role play
• Emotional lability
• High anxiety
• Intolerance of uncertainty
• Creativity (including verbally)

I was drawn to person centred counselling and the theory behind it many years before hearing of PDA, first as a client (seeking to solve my ongoing social interaction issues and unbearably intense emotional reactions), and then as a trainee counsellor (having been urged to do this by two of the person centred counsellors I'd seen because they felt I had a natural aptitude for the theory). In person centred counsellor training, I qualified at CPCAB Level 3 (permitting me to call myself a qualified counsellor), but dropped out after the first term of Level 4 as focus had shifted to agency employment and no longer harmonised with my PDA traits.

On learning of mine and my daughter's PDA, its impact and that we, her parents, had intuitively implemented every strategy recommended on PDA Society's strategies to try at home page (summarised below), I felt sure of significant overlap between PDA strategies and PCT (person centred theory), and had been mulling over composing this essay for some time. As I was a little rusty on PCT, I collaborated to produce this article with Kate Rushbrooke, who is both the mother of a PDA child and a fully trained, practicing person centred counsellor.

In brief, the strategies PDA Society suggest (edited here to cover interaction with PDA adults, as well as children) are:

Adjusting your mindset

• A more equal relationship, based on collaboration and respect
• Look beyond surface level behaviour
• Don’t take it personally and keep a cool head
• Treat every day as a fresh start

 Provide the optimal social environment

• Balance tolerance and demands – Accept that some days a PDAer’s anxiety is so high they will struggle to accept any demands
• Choose your battles
• Choosing non-negotiable boundaries
• Provide clear reasons for non-negotiable boundaries
• Natural rewards and consequences
• Keep exposure to busy social occasions manageable
• Fear of Uncertainty – Plan ahead so PDAers know what to expect

Adopt an indirect style of communication to reduce and disguise demands

• Use indirect commands to disguise demands and make them fun
• Allow PDAers space to be useful, this also helps to maintain emotional well-being
• Pretend you don’t know/get it wrong and ask them to teach you –– this might come across as patronising to older children and adult PDAers
• Offer choices to give control & autonomy
• Use a calm, even tone of voice
• Indirect praise
• Use of role play and props –– adults will be more likely to self-implement role play to bypass demand avoidance
• Model desirable behaviour –– PDAers will disregard arbitrary authority

Kate comments: the method of questioning within the person centred counselling modality is hugely in line with positive PDA strategies. Lots of open ended, indirect questions – “I wonder if ….” etc, etc

We will now examine a more in depth explanation of person centred practice (kindly provided by Kate) in relation to the PDA profile (described in the definition of PDA at the top of this page) and the strategies listed above.

Person Centred Therapy developed by Carl Rogers (1902-1987) in the 1940’s, held the belief that individuals are positively motivated from birth and possess the ability to uncover the solutions to their problems if offered the correct conditions. It was a theory that challenged the counsellor-led practises of its time, namely Behaviourism and Psychoanalysis, which suggested that human beings require professional direction. (Casemore, 2006, pp.40)

Kate: the fact that person centred counselling is not counsellor led is great from a PDA client perspective. The relationship is equal, the client does not need to fight for control of the situation.

My perspective: this tallies with the PDA strategy of having a more equal relationship based on collaboration and respect.

Therapists trying to lead me, no matter how benevolent their intentions, has always triggered demand avoidance causing me to disengage. Having gained awareness of my PDA, I noticed this in action during sessions with a person centred counsellor: I felt a switch in my head every time she invited me to sit with my feelings and told her my demand avoidance had been triggered. She was upset at first that I had misconstrued her good intentions, but I explained my demand avoidance is triggered regardless of intent. It even triggers, for example, on hot days if I notice it would help to take my jacket off. Demand avoidance makes doing this feel abhorrent, too much effort. This is nothing to do with how my body communicates that I am overheating, just that it has directed me at all.

Rogers’ beliefs were very much part of a Humanistic approach to life shared with other notable peers of the 1950’s. A theory based on the assumption that human beings continually strive for self-improvement in order to reach their self-actualization. An in-built desire to be the best possible person that they can be. One such peer, Abraham Maslow (1908-1970) developed the ‘hierarchy of needs’. A five stage pyramid identifying the levels that need satisfying in order to reach self-actualisation. (Wikipedia, 2009).

Kate: this sits comfortably with Dr Ross Greene’s theory that ‘kids do well if they can’. It is often assumed that the behaviours manifested by PDA children are ‘naughty’, ‘disruptive’, 'lazy', etc, etc - whereas a meltdown indicates that they are struggling with something.

Me: this ties with the PDA strategy of offering choices to give control & autonomy.

Other philosophies dating back to the early 19th century appear to have influenced the Person Centred model. Phenomenology, founded by Edmund Husserl in the 1850’s, holds the belief that “understanding of ‘reality’ comes from subjective experience” (Sanders, 2006, p.21) In other words, experiences can only be validated by the individual who is experiencing it, not objective others. This links in with the Person Centred view that each client’s experience of life is unique. No one else has the answers. Phenomenology also holds empathy at its core for understanding the client in the same way that Rogers insisted that empathy is essential for therapeutic success.

Kate: the belief in the ‘subjectivity of experience’ is of paramount importance to any client, but particularly so to someone on the autism spectrum who sees the word very differently to a person coined as ‘neurotypical’. The idea of therapy being subjective indicates the removal of the demands and judgement of others. A refreshing concept for PDAers!

Me: ‘subjectivity of experience’ connects to the PDA strategy of looking beyond surface level behaviour.

Additionally, a manifestation of the PDA tendency to judge people, rules, etc, on merit as opposed to arbitrary authority, is that we connect with what makes sense, and will actively reject a one size fits all approach. This tallies with the strategy of modelling desirable behaviour.

Assuming the role of client as the expert, it will come as no surprise that the success of Person Centred Counselling is hugely dependant on the counsellor’s ability to portray core conditions to the client. Furthermore, the client needs to be accepting of these core conditions. Not everyone is open to a non-directive form of therapy and may prefer to be offered solutions by the therapist.

Kate: ideal for a PDAer who would welcome the non-directive approach of PCC. A Person-Centred counsellor will not direct the session and will offer a blank canvas at the beginning of each session so that the client takes the reins and leads the conversation. Thus reducing anxiety.

CBT although it has its place in the counselling world is a lot more directive and structured in comparison to PCC and sometimes involves homework and consequently not as suitable for someone with PDA.

Me: placing the client in the role of the expert tallies with the PDA strategy of using role play to circumvent demand avoidance, but in this instance the offered role is specifically suited to gaining confidence, autonomy and personal freedom. A win win situation surely for a PDAer?

I feel this also underpins all PDA strategies, in that PDAers flourish only when our specific needs, including autonomy and personal control, are met. PDA Society equate our specific needs to those of giant pandas

"Giant Pandas are very sensitive to their environment and require very specific support and accommodations to thrive, without which they can become very unwell. It has been shown how an integrated approach to their care – combining science, a genuine commitment from multiple parties and community engagement is essential for success.

Similarly, the recommended support strategies for individuals with PDA are very specific and very different to those for people with other autism profiles. In place of firm boundaries and the use of rewards, consequences and praise, individuals with PDA respond better to an approach based on negotiation, collaboration and flexibility."

If people are indifferent to our needs believing they know better than us (taking on the role of expert) then friction and meltdown/flight/shutdown will result. I have heard countless times of teachers failing PDA children because "they know best", and parents agonising over how to train their PDA kids to "do what they're told". Traditional strategies do not work, but PDA strategies do, and we can see the strategies which do work are person centred ones.

Rogers believed that all human beings are born with a fundamental drive to be as successful as possible, even suggesting that the actualising tendency is part of the body’s natural DNA. (Casemore, 2006, p.40)

Me: this again accords with Dr Ross Greene’s theory that ‘kids do well if they can’.

Rogers described an Organismic Valuing Process whereby an individual who is given the correct love and support in their formative years will grow up to trust their real, or core-self, and thus go on to lead satisfying and fully functioning lives. Should individuals be unlucky enough to be denied these self-affirming attitudes, their belief in their ability to make the correct decisions may suffer and lead them to look to significant others for approval and guidance. (Mearns and Thorne, 2007, pp12-13).

The overwhelming need for positive-regard (or love and acceptance) from others is so strong within human beings that individuals can often disregard their own internal locus of evaluation (instinctive decision making), in favour of an external locus of evaluation of other people’s perceptions of what is best for them. For example, a child who asks his mother for a coat on a warm day because he feels cold, and receives the response “don’t be so silly, you can’t possibly be cold on such a warm day.” is likely to ignore his own instincts in a bid to achieve the approval that he desperately desires from his mother.

Rogers developed a model of personality to demonstrate how our core-self, which is present from birth, can erode when our self-concept or learned self,  forces us to behave in ways that do not correspond to how we really feel. This self-concept relates to how, as we mature, we build up a picture of ourselves in relation to the world around us and develop our personality in a way that fits in with others.

Kate: a PDAer would regularly distort or deny their experiences in favour of appearing to fit in with others expectations. Some parallels could be drawn between the mimicking tendency of PDAers and others on the autism spectrum in order to fit in.

The inconsistency of who we truly are and the person we project to the world can easily lead to anxiety and depressive thoughts. After all, anxiety is seen primarily as a product of incongruence or a threat to our self concept. We feel anxious when something does not sit comfortably with us. As PDA entails intense levels of anxiety, person centred theory fits extremely well.

Counsellors can help a client who struggles to process information and manage certain emotions that seem overwhelming. Fear, uncertainty, transitions and sensory and emotional overload are to name just a few of these.

Me: as PDA children cannot be moulded to parental and social expectations, we are especially prone to believing ourselves to be fundamentally wrong. This certainly was the case for myself growing up. I believed I was a hideous alien that could never, ever be good enough to be a real human. I attempted to hide my perceived wrongness behind a mask of mimicked normality. As Kate suggests, this caused me to feel enormous anxiety and depression. My self-esteem was pretty much zero.

The idea that individuals are only valued and loved if they behave in ways that are accepted by significant others are known as their Conditions of Worth. In time, these conditions can even become introjected in that an individual starts to believe that other people’s perceptions of their subjective experience actually originated from within himself “causing inner bewilderment which undermines confidence and makes effective decision-making impossible”. (Mearns and Thorne, 2007, p.13)

Kate: the importance of the above is that most clients on entering counselling will be in a state of incongruence and it is the counsellor’s job to loosen the incongruence so that the self-structure that a person has developed over the years can be broken down and reformed into a sense of being that closer reflects the true self of that individual. Because PDAers can exhibit behaviours that are so at odds with the expectations of society in which they live, I might suggest that the level of incongruence within them may be more acute than that of a neurotypical person. In this scenario, the counsellor can therefore assist the PDAer in letting go of the false beliefs that they have developed through other people’s expectations thus letting go of a considerable amount of anxiety.

Person centred counselling can assist a PDA client to separate their emotions and feelings from those of others. I express it by saying “that is their stuff not yours!"

Me: I have found person centred counselling incredibly beneficial in that it lifted me out of deep fugs of anxiety, depression and low self-esteem. Repeated person centred counselling (as many counsellors as I could access on my low income during the course of my younger adulthood) enabled me to slowly unravel the reality of my existence until having the epiphany that my remaining difficulties were not psychological, but neurological. It was less than six months after this revelation that I received my autism diagnosis.

Rogers believed that by offering the right core conditions the therapist could enable the client to explore their inner feelings in a safe environment and gradually help them reinstate their core-self.

Kate: The reduction of anxiety can better enable the PDA client to explore their world within the safe confines of the counselling room. They are enabled to express a fuller and more authentic range of experiences less modified by conditions of worth and previously denied experiences.

There are six core conditions

1) Both parties need to experience psychological contact. This constitutes both parties wanting to be in the therapeutic relationship, even if to a minimum degree. Experts believe that without the presence of a ‘real relationship’ between counsellor and client the other five core conditions are worthless. (Casemore, 2006, pp9-10)

Me: as described above, this relationship can be seen as therepeutic role play which purposefully empowers the client by giving them control.

2) The client needs to be incongruent. Even if they are unaware of their incongruence the client would not be seeking therapy in order to change if they felt that they were already in touch with and portraying to others their true self.

3) The therapist must be Congruent. Congruence can be referred to as realness, genuineness or transparency of the counsellor. Where the counsellor’s behaviour reflects what they are feeling, so that the client knows that they are being treated openly and honestly.

Kate: all of the above helps to build trust. Trust is massively important for PDAers

Me: congruence is extremely important for PDAers as we rate people on merit rather than rank. A PDAer will not automatically trust or respect a therapist, we need to feel that they are genuine for this to happen.

4) Unconditional Positive Regard (UPR) refers to the non-judgmental attitude of the counsellor, where they deeply value the client no matter how they behave. This demonstrates to the client that they are valued for being who they are and not by the standards and expectations set by significant others.

Kate: again, UPR is totally in line with a successful client counsellor relationship when considering the struggles experienced with PDA.

Me: I feel congruent unconditional positive regard is hugely important to PDAers as, despite our masking tendency, we feel huge social anxiety, often coupled with intense fear of rejection. I feel this ties with the PDA strategy of using a calm, even tone of voice.

Kate: Voice control is also very much considered in a PC environment. The absence of judgement results in a situation or feeling being neither good nor bad and therefore “it just is”.  The result is a counsellor who’s tone of voice remains calm and ‘non accusing’. I believe this is very helpful for PDAers who can be highly sensitive to any suggestions that may be conveyed through tone of voice.

5) Empathy. The Therapist also experiences empathy for the client. Empathy can be described as walking in someone else’s shoes to experience life as they see it. The need for the counsellor to put aside their own perception of reality and instead adopt the perceptions and experiences of the client which helps them to “appreciate how the client experiences the events in his world” (Mearns and Thorne, 2007, p.67).

Kate: so important for someone who has struggled with constantly being misunderstood.

An empathic counsellor will wait for a client to formulate their thoughts – this is fabulous for a PDA client who may struggle to verbally express themselves and keep up during conversations

Me: I believe empathy is a hugely powerful tool. To be finally understood after a life time of failing to fit society's expectations can feel like water in the desert.

6) The client needs to perceive the UPR and empathy that the therapist holds for them, even if this is only to a minimal degree. The therapist therefore needs to communicate these feelings effectively so they can build a trusting relationship with the client.

Me: it is important to find counsellors we connect well with. Although all person centred counsellors adhere to the above described model and wear their "expertise as an invisible garment" (Mearns & Thorne, 1977) in reality we may connect better with one counsellor than another. I know this to be true from my own experience of having been the client of over eight person centred counsellors, of whom some I saw just once knowing I'd not connect with them. I have spoken to more than one adult PDAer who said person centred counselling didn't work out for them, usually because they didn't drop their masks and the counsellors believed them to be OK.

Kate: where a client struggles to understand other people in the way that may come naturally to a neurotypical person, the counsellor can assist in communicating general social expectations and social nuances, again in a safe, confidential environment.

Me: I have personally benefited from counsellors acting as social interpreters for me. For example, when baffled by unexpected social friction, counsellors have been able to clarify what others involved may have felt. They have often, however, been troubled by my tendency to analyse social situations in place of exploring my feelings. My adult autism diagnosis enabled me to understand that, rather than my analytical way of thinking being the result of emotional trauma, this is just how I am wired.

All in all, I would say person centred counselling can be uniquely helpful for PDAers because of its inherent non-directive ethos. However, the therapy process is an active one. We must choose to enter the relationship, feel comfortable with the counsellor, accept control and remove our masks enough for our real issues to be expressed and explored.

In the light of all this, I believe the above listed PDA strategies can be equated to person centred theory thus:

A more equal relationship, based on collaboration and respect –– the therapist is not the expert in the relationship: each client’s experience of life is unique. No one else has the answers
Look beyond surface level behaviour –– our core-self, which is present from birth, can erode when our self-concept or learned self, forces us to behave in ways that do not correspond to how we really feel
Don’t take it personally and keep a cool head ––  the non-judgmental attitude of the counsellor, where they deeply value the client no matter how they behave
Treat every day as a fresh start –– the counsellor to put aside his own perception of reality and instead adopt the perceptions and experiences of the client
Balance tolerance and demands – Accept that some days a PDAer’s anxiety is so high they will struggle to accept any demands –– empathy at its core for understanding the client
Choose your battles –– build a trusting relationship with the client
Choosing non negotiable boundaries –– the client knows that they are being treated openly and honestly
Provide clear reasons for non-negotiable boundaries –– demonstrates to the client that they are valued for being who they are and not by the standards and expectations set by significant others
Natural rewards and consequences –– The Therapist also experiences empathy for the client
Keep exposure to busy social occasions manageable –– appreciate how the client experiences the events in his world
Fear of Uncertainty – Plan ahead so PDAers know what to expect –– the need for the counsellor to put aside his own perception of reality and instead adopt the perceptions and experiences of the client
Use indirect commands to disguise demands and make them fun –– enable the client to explore their inner feelings in a safe environment
Allow PDAers space to be useful, this also helps to maintain emotional well-being –– all human beings are born with a fundamental drive to be as successful as possible
Pretend you don’t know/get it wrong and ask them to teach you –– this might come across as patronising to older children and adult PDAers –– individuals are positively motivated from birth and possess the ability to uncover the solutions to their problems if offered the correct conditions
Offer choices to give control & autonomy –– each client’s experience of life is unique. No one else has the answers
Use a calm, even tone of voice –– given the correct love and support  [...will...] trust their real, or core-self, and thus go on to lead satisfying and fully functioning lives
Indirect praise –– appreciate how the client experiences the events in his world
Use of role play and props –– adults will be more likely to self-implement role play to bypass demand avoidance –– assuming the role of client as the expert
Model desirable behaviour –– PDAers will disregard arbitrary authority –– where the counsellor’s behaviour reflects what they are feeling, so that the client knows that they are being treated openly and honestly

Kate Rushbrooke's website is www.katerushbrooke.co.uk and her email address info@katerushbrooke.co.uk.  She counsels both children and parents either face to face or via Skype.