In the summer of 1999, I was a new father and embarking on a new journey both at home and in my work life. A year earlier, I had taken a leap into an unfamiliar and strange territory. I had begun working with developmentally disabled adults in a six-bed group home in Sonoma County California. My work in that house had prepared me well for dealing with individuals with “challenging” behavio
I had received training and well over a thousand hours of practical and supervised experience in implementing and designing behavior modification programs based on the traditional behaviorist line of reasoning. My clients up had consisted of a mixed bag of Paranoid Schizophrenics, Obsessive-Compulsives and individuals who were more difficult to pigeonhole but who nonetheless shared global developmental delays and challenging behavior.
Using standard techniques that had me counting and recording the minutiae of my client's everyday life I was able, to some extent, to formulate living arrangements designed to make use of their positive behavior while limiting the stimuli that would evoke their more destructive behaviors. I also got to teach a number of middle-aged people how to brush their teeth, take a bath and make a meal, as did everyone else who had worked with them during the previous twenty years.
In the home setting, staff turnover and a lack of a proper fading plan for the tasks being learned had created six extraordinarily prompt-dependent individuals who had a difficult time achieving any real independence in their daily lives. Frustration with the inadequate implementation of behavioral change plans prompted me to leave the house and move to a large agency. I hoped that by working at that agency I could learn new techniques and could perhaps become more effective as a teacher and companion to my clients.
I remember my first meeting with the person who would hire me; she seemed to me to be a well-grounded, a centered individual who possessed an air of competence and kindness that was rare in my experience. I began work immediately and was quickly inundated with month's training. Besides the standard information about first aid and CPR, State health regulations and safety standards, I was again immersed in the world of behaviorism. For two months, I attended workshops and read everything that was available to give me a tool kit for training my clients.
The agency served over 200 individuals with developmental disabilities that ran the gamut of descriptors. Begun in the 1960's as an alternative to institutionalization by parents of children with special needs the wholesale release of the mentally ill from California hospitals in the late 1970's and early 1980's had filled the program with a host of individuals who faced significant challenges to community inclusion.
Of the many and varied diagnosis that the people in my agency were labeled with, “autism” was widely regarded by the staff and management as a label to be feared. The autistic individuals tended to exhibit the most extreme behavior. They would attack staff, run away, and assault random citizens. They were particularly prone to bizarre-looking actions such walking on the tips of their toes, screaming at apparently random intervals, and masturbating in public. Of course, my job was to be the primary instructor for the single most challenging individual in the agency.
Drew was a tall thin man in his early thirties. I remember the first time I met him, accompanied by the lead instructor, a senior staff member in charge of the daily programming for a group of clients, who had been personally working with him on a daily basis for the past six months. Mike was about my age and barely hanging on. He was showing all the signs of burnout. His appearance was disheveled, his paperwork was always late and he talked about moving into a new job as soon as I was trained. Drew did not talk at all.
The program for Drew consisted mainly of picking him up at his group home in the morning, which was run by a wonderful woman whose knowledge of the field and understanding of the disorder was immensely valuable to me, and then keeping him as far away from the public as we could. “Drew likes to walk,” Mike told me on our first meeting, and indeed it seemed as if he did. Walking on tiptoes all day long along forest trails, park benches, rocks and walls was what Drew did. That and eat. Drew would eat anything in the wild. Rotten apples fallen to the ground were a particular favorite but so were most plants. Drew had a reputation for violence and unpredictability but by the end of the first two weeks accompanying Mike and Drew I was really looking forward to using my shiny behaviorist tools and techniques.
With Mike gone, I began to work with Drew in earnest. Each morning I would arrive at his house to pick him up. There I would be given a briefing on his general health, mood and any noteworthy behavior observed during the previous night or over the weekend. Once I had Drew safely in the car we would drive to some of the most beautiful locations in the region to walk, have a snack, walk some more, have lunch, walk some more and finally return home.
For the first month, I did absolutely nothing other than ensure his physical safety and record any instances of noteable behavior. I maintained his safety, and presumably that of the publics, by confining our outings to the wide-open spaces of bucolic rolling hills, redwood groves and coastal areas.
My task was to reduce Drew's need for supervision. To do this I was to use the standard techniques of positive reinforcement coupled with a stringent analysis of antecedent behavior, and consequences over time. Ideally, Drew would be able to be included in a group with a higher ratio of staff to client, perhaps 1:3 or 1:6 as opposed to the 1:1 that he received. There were significant financial pressures on the agency to reduce staffing levels, and 1:1 services were being reduced throughout the State.
Unfortunately, behavioral techniques simply did not work with Drew. The data I gathered showed a tendency toward randomness that, at first, made no sense to me. I was not approaching this particular task from a totally naïve standpoint, although my understanding of Drew's experience was minimal at best. I spent months studying autism. I read books and journal articles. I spoke with experts in the field and routinely met with the director of Drew's living program for advice and counsel about how to best manage his behavior. But it was not until I read Temple Grandin that I began to have some kind of clue as to what was going on with my client. “I think in pictures. Words are like a second language to me. I translate both spoken and written words into full-color movies, complete with sound, which run like a VCR tape in my head. When somebody speaks to me, his words are instantly translated into pictures.” (Grandin, 1996)
Drew showed no understanding of the connection between behavior and consequence. His affect was bizarre to the untrained eye, this tall and slightly messy man with curly black hair and slightly bulging eyes. He always stood on tiptoes and often would press his eyeball from the side with a dirty forefinger. He would grin broadly at no apparent provocation and at other times would frown, lips hanging loosely, looking for all the world as if he were intensely worried about something. Often he would hold a piece of grass between the fingers of one hand and constantly spin it. Sometimes he would erupt into a maniacal rage in which he would stomp in lurching circles while screaming “Na, na, na, na” while pulling his hair furiously. Occasionally he would lie down on the grass and begin to “hump” the ground; sometimes he would simply begin to masturbate while in a park, riding in the car or any other location where the inclination struck him.
Antecedents were difficult to identify. His behavior would occur in places where there was no one around but the ocean and me and at other times in crowded spaces. Morning, noon, afternoon, winter, spring, summer and fall he would engage in his various behaviors, but over time the list of behaviors became well defined and the frequencies remained fairly steady. Behaviorism had failed in this respect: Drew seemed to have a decidedly different sense of everything, time included, that tended to render the rewarding of behavior moot and the management of antecedents nearly impossible without understanding his personal experience of the environment.
Drew never spoke to me. He never really spoke to anyone, and he tended to look at people in a sideways manner if at all. This made any kind of verbally-based approach dicey, to say the least. After three or four months, I was ready to try anything. I began by reading to him. Byron, Poe, Kipling, the newspaper, anything I could find or may be interested in sharing. He didn't seem to like that very much and would move away from me. Music likewise seemed to make little impression on him, though heavy metal tended to make him rock back and forth a bit more than country. Then one day as I was trying to keep him from eating a particularly nasty bit of used food from a garbage can, it dawned on me that although Drew did not seem to notice much in his environment, he always, always spotted food.
Gestalt therapy pays particular attention to interactions between the organism and the environment (Baumgardner & Perls, 1975). In healthy organisms, at any given time there are many needs. The need with the highest valence becomes dominant and stands forth from the ground as the figure. As Drew searched his environment looking for meaning, the world was a vastly different place than for him than it was for me. His very senses seemed to work in strange and unpredictable ways, but he could always be certain of finding food somewhere within the chaos of information that he was processing. His activity was focused on a prolonged search of his environment for the object of his desire, food. He lived in a world of unfinished gestalts and the finding of food was his attempt to assimilate the environment and close the gestalt. As understood by Koffka, it was the connection between sensory and motor activity. As understood by Lewin, the energy freed by consuming a tasty tidbit was then, ideally, released for further activity. In Drew's case, however, there was no further activity. His pattern of action was a cycle, a knot.
Another aspect of the experience of living with autism involves the concepts of boundaries. Autistic individuals, by dint of their sensory fragmentation and impaired ability to differentiate between sensory signals and thought forms, develop a characteristic that can be considered in these terms. The intra-psychic boundaries of Drew's mind were weak if not altogether absent. The world apparently flooded in through his entire sensory apparatus, making a confused and perhaps frightening myriad of impressions.
In Drew's case the anxiety-producing aspects of his sensory relationship to the world led to sudden screaming, high-frequency movements, and sometimes aggressive behavior toward intervention. He showed no understanding of the world around him or the dangers therein. He would blindly and suddenly dart into traffic. Yet he could differentiate heights as along a rocky coast with no apparent trouble. His responses to other people, even to me after two years, were minimal or invisible. This inability to differentiate clearly between self and others, between his body and threats in the environment. suggested that his boundaries with the outside world, his life-space, were hopelessly confluent.
Behaviorism provided a fragmented approach for teaching a fragmented individual. The techniques of task analysis and functional analysis proved to be ineffective in working with this autistic individual for what I surmise are the following reasons: First, the internal world of the severely autistic person is apparently one in which thought and reality are confluent. In a sense it seems as if the individual has embarked on a life long acid trip and from that psychedelic state of mind linear and fragmented instructions may be far more confusing than a more Taoist or gestalt approach. Second, another weakness of a behavioral approach lies in the consistency and structure required of the individuals involved in the program. The fragmentation of tasks to be learned into discrete steps (Donnellan et.al. 1988) requires a supreme consistency in approach and a clear plan to fade assistance over time. In the life of autistic individuals, however, the people who work with them tend to leave with a disconcerting frequency. High staff turnover means that the autistic learner must begin again with each new staff person. I was no exception.
It was only when I stopped "working on" Drew and began to "be with" him that I saw any increase in his adaptive functioning. Eventually I simply witnessed the man in his environment. When I spoke with him I was mindful of maintaining an even tone that was consistent across environments. I made sure to frequent familiar places and kept my physical interventions simple. If he was in danger I would redirect him with a slight tug on his shirt and a quietly spoken “This way, Drew.” Over time the consistency of my affect and the gentle, non-directive approach enabled him to respond with more consistency to my requests.
Drew began to use sign language, primarily just the sign for “Yes,” when I asked him a question. This enabled me to check in with him directly rather than through inference. Over a couple of months his disturbing and self-endangering behaviors began to decrease, but not yet to a level where he could be in a larger group. I began to experiment by bringing him in to locations that were more and more populous, much as in the method of in-vivo desensitization. At first he show his usual signs of agitation but eventually he developed a tolerance for new locations. In this process I had to be completely engaged with the man. His every move, every twitch had to be decoded as a possible sign of discomfort, just as in the Gestalt Therapy principle of "paying attention to the obvious."
As a naïve individual engaged in psychological work, this aspect of being present and wholly engaged in the being of another was my first introduction to a Gestalt perspective. Over the following months this seemingly simple process of acceptance, observation and minimal prompting enabled Drew and I to move into ever more sophisticated venues. A part of the mission for agencies that work with the developmentally disabled is to provide opportunities for “integration”. For the most part this means "work," however minimal and contrived. Drew was as unsuited for work as almost anyone who has ever lived, yet a measure of success with him was the fact that at one time he did, by a strict definition of the word, work. I had been bringing him to a nursery owned by some friends for about three months. Twice a week we would arrive and walk rapidly through the greenhouses and around the potting area. The owner had agreed to hire Drew to perform a simple task, dumping dirt from used containers and stacking them into a pile.
Engaging Drew in any kind of task was difficult and task analysis was insufficient to transform him into a productive member of the workforce. As it turned out, an awareness of his unique experience of the world, however subjectively obtained, proved to be the key to gaining some measure of cooperation in the task. Drew had an uncanny ability to spot edible plants. He could differentiate in the wild between anise, mustard, blackberries and inedible material. In that environment, he would move through the ground to the figure of his attention. In the nursery where we were surrounded by edible plants, the figure became the ground. He became attracted to one plant in particular. Unfortunately, it was a Habanero pepper plant. The first time he grabbed one and ate it, I was more than a little frightened. His howling afterwards was eerie and as I rushed water to him, he drank greedily, spilling the liquid on himself and me in his attempt to cool the burning. After a few minutes, he began to calm down, looking askance at the peppers. Then, for the first time really, he engaged me by tugging on my shirt. He was asking to go.
We came back at our usual time and he ate peppers on occasion but each time he seemed to be less distressed. While he would engage in his usual perambulations I began to direct him through little tugs on his shirt to the work area where I would model the desired work behavior for as long as he would watch. When he needed to move or go he would tug on my shirt and we would go at that moment.
After a few weeks Drew tugged on my shirt and I said simply, “Sure Drew, we can go, but please dump out this pot for me and toss it in the pile.” He did. The next week he did three pots, and the week after that a few more, but never more than a few minutes at a time. In the end, it was the development of a personal relationship coupled with wholly transparent communication that enabled Drew to work for a short time, and to maintain his grounding even in the middle of a shopping mall.
At about this time my work with him was to end. I had been offered a position leading a team of instructors who would work with the most intransigent cases of maladaptive behavior. After training another staff person to work with Drew and overseeing their relationship develop over a period of weeks I took up my new post.
Years later when I would run into Drew at the agency or in the community I would always wonder if he would remember me. For all I knew, to him I may have resembled a screeching Picasso painting come to life, in a weird stop-action way. My curiosity was answered when after having not seen him for six months I saw him walking with a new instructor near our agency's campus. He was agitated and the instructor seemed frustrated at her inability to calm him. Walking up to him as he paced frantically I tugged on his shirt and said,“This way Drew.” He began to follow me and we walked around the block in that same silence we had known together for so long. When we returned he got into the instructor's car, she thanked me, and I waved goodbye to the man with the open grin on his face, who was rocking back and forth in the backseat of yet another stranger's car. In a brief moment of eye contact with him before they pulled away I sensed a kind of momentary happiness, like someone may feel when they have clung to a piece of wood in a raging storm at sea. For Drew the storm would continue for the rest of his life. I could only hope that his future strangers would be able to provide him with those brief moments of grounding, or respite, that he so desperately needed.
Resources:
Baumgardner, P. and F. Perls. (1975) Legacy from Fritz and Gifts from Lake Cowichan. Palo Alto, California: Science and Behavior Books, 1975.
Baron-Cohen, S. (1989) "The autistic child's theory of mind: A case of specific developmental delay." Journal of Child Psychology and Psychiatry, 30, 285-297
Donnelan, A., La Vigna, W., Negri-Shoultz, N., Fassbender, L. (1988) Progress Without Punishment. New York and London: Teachers College Press
Grandin, T. (1996). Thinking in Pictures and Other Reports From My Life with Autism. New York: Vintage Books
Koffka, K . (1935) Principles of Gestalt Psychology. London: Kegan Paul, Trench
Hartmann, G.W. (1935) Gestalt Psychology. New York: The Ronald Press Company
Lewin, K. (1935) A Dynamic Theory of Personality. New York: McGraw-Hill Book Company, Inc.
Lewin, K. (1936) Principles of Topological Psychology. New York: McGraw-Hill
Perls, F.S. (1969, 1972) In and Out the Garbage Pail. Lafayette, California: Real People Press; New York: Bantam Books
Lew Brown has been a staff member in a variety of residential treatment facilities. He is currently studying at Sonoma State University, with a focus on research methods and Gestalt process. He can be e-mailed at <brownle@sonoma.edu>
