Exposure Therapy Is Ineffective For Most Autistics
Especially with regards to sensory sensitivities and trauma
I can’t even with these psychologists
Every single assessment report I’ve read from every psychologist who has determined a child is Autistic includes in their recommendations Applied Behavioural Analysis (ABA) and various forms of behaviour therapies.
(I’ve written extensively on the harms of ABA, so I won’t delve further into that pile of flaming — I mean, I won’t go into that here).
Many of the assessments which have made a diagnosis of autism also include co-occurring conditions such as ADHD, OCD, and anxiety. When a person is diagnosed with anxieties and phobias, guess what those psychologists fall back on yet again?
Good old-fashioned behaviourism. (Ugh). It’s like they’re one-trick ponies. (Sorry psychologists, I know there are lots of fantastic clinicians out there, but I grow weary).
Many clinicians recommend behavioural therapies such as graduated exposure (or systematic desensitization) for phobias, OCD, and sensory sensitivities.
Systematic desensitization is done in a safe, controlled environment wherein the patient is exposed to the fearful stimuli, beginning at the lowest tolerable level of the stimulus, then very gradually increasing in intensity.
For some (especially non-autistic folks) this may be highly beneficial and helpful. Psychologists really need to get themselves up to speed on current research, however, before recommending these approaches for Autistics.
Studies have demonstrated that the Autistic brain responds very differently to sensory stimuli when compared to neurotypical (NT) folks.
What seems to happen (in lay terms)
The amygdala — the fear centre of our brain — responds to aversive, unexpected, or threatening sensory stimuli in the environment. The amygdala’s job is to alert us of potential danger, so this is good.
In neurotypical (NT) folks, once they recognize the sound or are assured the stimulus is not a threat, their amygdala tends to stand down. The related sensory cortices in their brain habituate (or get used to) the incoming stimuli and learn to ignore it, or at least pay less attention to it.
In sensory over-responsive Autistics (or Autistics with sensory hypersensitivities), the opposite occurs.
The more we are exposed to sensory stimuli, the more our amygdala sounds the alarm. Our sensory cortices do not reduce their response, which sends our nervous system into a state of high stress.
A brief summary of the evidence:
- Studies have revealed consistent patterns of reduced habituation in autistic participants.
- Autistics with high sensory over-responsivity showed reduced ability to maintain habituation in the amygdala and relevant sensory cortices and to maintain inhibition of irrelevant sensory cortices.
- Autistic children have significantly reduced habituation relative to Neurotypical (NT) children for both auditory and visual stimuli.
When an Autistic person is subjected to graduated exposure therapy, one of two things are likely to happen:
- The nervous system becomes so overwhelmed, it eventually goes into a state of overload, leading to either meltdown or shutdown.
- The individual learns to suppress their external response (learned helplessness), but their internal response remains the same, or even increases in intensity due to sensitization.
Learned helplessness
In order for learned helplessness to occur, three factors much be present: contingency, cognition, and behaviour.
Contingency
Contingency means there is a clearly identifiable relationship between our actions and an environmental response.
For example: someone turns music up to a very high volume and I cover my ears, which leads them to turn the volume down for me. The music being turned down was contingent on the behaviour of covering my ears. The person saw I was in distress and acted to relieve my discomfort.
If there is very loud music playing and a person covers their ears or calls out to turn it down, but no one listens (or worse, says “it’s not that loud, relax!”), then there is no contingency between their behaviour and the environmental response.
Having our behaviour or distress ignored contributes to a feeling of helplessness, especially when we have little or no control over the environmental factors which are causing our discomfort.
Cognition
Cognition is another word for thinking. Regardless of whether there is a contingency present, whether the individual recognizes and believes there is a contingency also has a significant impact on whether they feel a sense of helplessness or a sense of agency.
If a person has been taken seriously when they express sensory discomfort, they will have a belief that acting to relieve this will be effective.
If the person has a long history of being dismissed and invalidated, they will have a belief (based on experience) that their actions will not make a difference.
Behaviour
Behaviour describes how we respond when there is no contingency, or we believe one does not exist.
If experience has taught you that your behaviour won’t have a positive impact on your surrounding environment, and won’t be successful in reducing your distress, then you may give up trying altogether.
When these three factors are at play, this leads to what psychologists Martin Seligman and Steven Maier termed learned helplessness. Feeling as though we have little or no control over the negative experiences in our lives can lead to apathy and depression.
How about we start respecting Autistic people
Even children! A radical idea, I know.
The whole “this person doesn’t respond to the world like the rest of us, so we must modify their response” is — like me — getting old.
If an individual experiences distress over their sensory sensitivities and they want to explore ways to become more tolerant of certain stimuli, then by all means, let’s support them to reach their own goals.
Most of the assessments I read, however, are for children. These children have little to no choice in the type of treatment to which they are exposed. Their parents are often brand new to autism and have no idea what is helpful, what is safe, and what is potentially harmful.
Parents are trusting the professionals to be the experts and to make recommendations that are in their child’s best interests.
Clinicians, it’s your duty to ensure the referrals and resources you provide live up to that standard, and I’m sorry to inform you, most do not.
Many aren’t even supported by the most current evidence. Please, update those office handouts and those copied and pasted recommendation summaries you include with your reports. They’re tired, they are badly in need of a makeover.
And for the love of humanity, stop recommending behavioural therapies! The 1950s want their treatment plans back, and we don’t need ’em anymore.
© Jillian Enright, Neurodiversity MB
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References
Gandhi, T. K., Tsourides, K., Singhal, N., Cardinaux, A., Jamal, W., Pantazis, D., Kjelgaard, M., & Sinha, P. (2021). Autonomic and Electrophysiological Evidence for Reduced Auditory Habituation in Autism. Journal of Autism and Developmental Disorders, 51(7), 2218–2228. https://doi.org/10.1007/s10803-020-04636-8
Green, S. A., Hernandez, L., Lawrence, K. E., Liu, J., Tsang, T., Yeargin, J., Cummings, K., Laugeson, E., Dapretto, M., & Bookheimer, S. Y. (2019). Distinct Patterns of Neural Habituation and Generalization in Children and Adolescents With Autism With Low and High Sensory Overresponsivity. The American Journal of Psychiatry, 176(12), 1010–1020. https://doi.org/10.1176/appi.ajp.2019.18121333
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