Download The value of psychotherapy for adults with Fetal

The value of psychotherapy for adults with
Fetal Alcohol Spectrum Disorders
by Paul Estenson, Ph.D.
Reprinted with permission from The Iceberg newsletter, June 2003 www.FASiceberg.org
Most adults with FASD struggle with staying out of harm’s way. They regularly experience negative
consequences because they have significant problems discerning information that is relevant to making an
appropriate and safe decision. Also, adults with FASD tend to have difficulty correctly anticipating the probable
outcome of a course of action.
The worries of parents of adults with FASD tend to focus on the ongoing likelihood of poor decisions and the
unhappy outcomes that typically follow. Parents also share a deep concern about the limited social and
occupational opportunities that exist for these young adults with FASD. Parental concern about these limited
opportunities reflects a very real cultural and political problem.
Some young adults with FASD react to the problem of finding themselves in trouble by becoming passive and
taking little initiative. Unfortunately, this approach makes them more dependent upon others and creates the
conditions for a constricted, sparse life. Some young adults with FASD find themselves in a highly structured
setting that typically offers too few choices and too constricted a range of experience. The most common such
setting is the correctional system, a setting in which such young persons are particularly vulnerable.
What role can psychotherapy or counseling play in helping the adult with FASD cope with the problems that
typically go hand in-hand with FASD? Despite the wonderful diversity of individuals affected by FASD, there
are a number of common elements and directions that emerge. Combining these elements and directions as
needed is the course of effective therapeutic work with adults with FASD.
Life coaching
Treatment tends to focus on what Barb Wybrecht, a Michigan public health nurse and advocate for children with
FASD, has called “life coaching ”—an ongoing real-time reflection about events and choices as they occur.
Much coaching is devoted to surveying the different areas of life, for example, work, social relationships,and
personal habits,exploring how to discern relevant information, and providing input on likely outcomes of
different plans of action. Keep in mind, however, that people do not always follow the advice of their coaches,
and that coaches are not always right.
Using multiple sources of information about the person’s life
Acting as a coach can be challenging because many adults with FASD are not good informants about their
interactions and their own behavior. Also, because adults with FASD often do not see problems coming, a
conversation about “problems or potential problems ” may not be very useful. Inquiring more broadly about
what is going on in a particular setting will likely yield more useful information.
Getting information from other sources, especially from parents who have known the adult over time, will lead
to a much better sense of how things are going for the adult with FASD. Accurate, comprehensive, and robust
information increases the likelihood that counseling or psychotherapy will help construct a positive life story for
the adult with FASD, instead of serving as a format for the review of bad news.
Offering sustained low-intensity psychotherapy
An important complement to life coaching is that the psychotherapist and adult with FASD maintain contact
over time. However, once the client and the psychotherapist have established a way to talk relevantly about
issues and events, meeting less frequently but over a longer period of time has advantages. Behaviors and
problems are often patterned and recurrent.
Once the psychotherapist and adult client together discern these behaviors and patterns,they can monitor and
apply this information to new situations as they emerge over time.
Focusing on social mores/social acceptance
Adults with FASD often struggle to accept the people who are accepting of them.They often misread the signs
concerning the intentions and reactions of others. Adults with FASD are often confused and misled by media
representations of relationships, particularly the highly sexualized, “no means yes” norms suggested by these
media representations.
Real relationships and real expectations between people typically do not operate the way the media depicts.
Focusing on specific, unambiguous, and
real-life norms and laws, and on learning and using explicit ways of verbally checking out assumptions, is
central to supporting the challenge of developing a robust and happy social life for the adult with FASD.
Clinical example
A 24 -year-old male client followed a similar pattern in each of his jobs. Early on in a job, he had trouble
quickly learning new skills and routines, and he had trouble communicating his needs concerning these skills
and routines. My client was in danger of appearing unmotivated or far less capable than he really was. Later, as
he became more comfortable at a job, he had a strong desire to alter and add to how things were being done. At
times he persisted in his creative efforts in ways that were perceived as insubordination. Helping him and his
bosses understand this supposed insubordination became critical to his keeping the job.
As he became more comfortable at work, this young man met many of his social needs through his job.
However, he frequently misinterpreted friendliness, especially from kindly young women, as interest in a fuller
relationship. His persistence in pressing for his preferred definition of the relationship caused frequent problems.
The trajectory of his life on the job tended to follow this path. Being on the alert and open to signs of these
problems emerging was an important part of making the psychotherapy about change instead of about support.
It is important to note that the individualized arrangements that allow a job or social arrangement to work may
be undone by a change in management or a change in practices at the work or social setting. One cannot assume
that information and accommodations that initially allowed for a successful work/social experience will be
carried down over time. A time of change is generally a time to be on high alert.
Psychotherapy or counseling which incorporates the features described above will be an asset for the adult with
FASD. Coaching the adult with FASD over time to accurately assess situations, behavior, and experiences
should be a part of the standard of care for adults with FASD.
Dr.Estenson is a licensed clinical psychologist in private practice with Ann Arbor Center for the
Family in Ann Arbor, MI. Particular interests include issues related to compulsive/addictive
behaviors, chronic illness, and older adults. He has had extensive experience with hospital treatment
of substance abuse and psychiatric problems and with consultation to both treatment settings and
schools.