When I was a graduate clinician at Florida State University, I saw my first client in the clinic on campus. I learned about autism in undergraduate coursework and in my spare time I checked out books on autism in the library. When my supervisor, Ms. Jackson, went over clients, I expressed interest working with Billy, a 5-year-old boy with autism. Billy was the first person I met who had a diagnosis of autism that I knew of.
I don’t remember my first session with Billy, but I remember his third or fourth session. I had the therapy room prepared and ready, with all of the activities Ms. Jackson approved of. I knew she was going to observe one of my sessions, but I didn’t know today was the day!
As I walked Billy and his mom back to the therapy room, Billy’s mom mentioned that he was getting over a little cold so he wasn’t feeling his best. I could see Billy’s eyes were red and I could hear his nose sniffle. So my well thought out plans ended up going out the window. I tried doing a puzzle at the table and I tried to engage with Simon Says to work on following directions. Today he wasn’t feeling well and he wasn’t going to comply with my well thought out plans. As soon as I realized it wasn’t going to work, I decided to watch Billy and follow his lead.
Billy went under the table, so I went under the table with him. I could see a shift in him. He seemed calmer. He was looking at me and seemed more focused. He was engaging with me more. I was even able to sneak that puzzle from off the table and we did it under the table. After the initial struggle of the therapy session, I felt like we were connected. I felt like we were in the zone together focused on his goals.
It felt like a private moment, but it wasn’t. I knew his mom was watching. What I didn’t know was Ms. Jackson was observing me for the first time. I don’t know how long she was watching for but all of a sudden I heard over the intercom, “Is it appropriate to be under the table?” That beautiful little moment we created shattered that second.
Clearly my supervisor didn’t approve of my decision to go under the table. As a graduate clinician, I needed to follow my supervisor’s recommendations so then I changed my shift away from working on his communication goals and engagement to getting him to comply with the direction to sit at the table. Billy cried and ran around the room. It seemed like I kept chasing him around the circular table with no end. On the outside I looked calm, but inside I was a wreck. No matter how hard I tried, Billy was not going to sit at the table. I literally tried every strategy I knew at the time. He just kept crying and I just kept trying to get him to sit. If I did get him to sit it was brief and he just cried. I felt like a failure.
When the session was over, I took Billy back to his mom in the observation room in defeat. Ms. Jackson wasn’t there anymore. Mom must have known how I was feeling. She gave me a sympathetic look and said I did a good job trying.
When I went home that night, I felt like the worst graduate clinician ever. I kept asking myself if I made the right decision to become a speech language pathologist. Maybe I should just change my major now since I was a complete failure. When I thought I was doing something right, it turned out to be wrong. I had so much insecurity and doubt in my skills at that time.
Now as a speech language pathologist and Certified Autism Specialist with over 16 years of experience, I enjoy reflecting back on this therapy session. I didn’t have the knowledge then that I have now. I just followed my intuition. I just followed Billy. Knowing what I know now, I still stand by my decision to go under the table.
Billy had autism and he was sick, so his sensory system was probably more sensitive than usual. If I were to make a guess now, I would say Billy went under the table to avoid the florescent lighting in the clinic. At that time, I didn’t know that people with autism can be sensitive to florescent lights. I heard Temple Grandin mention this once in a training course I took. I didn’t know much about the sensory system and understanding different states of arousal. Billy was in a state of hyperarousal when under the florescent lights. When he felt like that, he wasn’t able to focus and learn. Going under the table was a coping strategy to get his nervous system back into a ready state for learning. He was calm under the table and we got work done. I wasn’t following social norms. I just followed Billy. I didn’t understand his needs at the time. I just knew I needed to follow him. If I had the same understanding as I do now, then I might have turned off the florescent lights and used an alternative form of lighting.
I respected Ms. Jackson and I can totally understand her viewpoint. It isn’t socially appropriate to sit under table. So she was focusing on following social norms. Some therapists focus on making autistic kids “look normal” so they discourage anything out of the norms – like going under a table, flapping hands, etc. Fortunately, this therapeutic viewpoint has been decreasing throughout the years with the help of many adult autism advocates.
Instead of telling children with autism “no” and “You should be….”, professionals need to take a step back and ask, “Why?” Barry Prizant explained why asking this question is so important in his book called , “Uniquely Human.” When the professional or parent can determine “why” then they can better understand the child’s needs and communication attempts.
Barry Prizant’s approach is so much more autism centered and focused on individual needs instead of focusing on society’s norms. Of course we need to take everything in mind when treating the child, but our approach should always be child centered.
That day with Billy was a very powerful day in my therapeutic history. Looking back and reflecting on it, I didn’t learn anything from my university teacher that day. Instead my teacher was a 5-year-old autistic boy. He taught me to listen when he didn’t say any words. He taught me to follow him and listen with my empathetic sense. He taught me to think outside the box and to let him be my leader.
Disclaimer – This blog is not intending to advise graduate clinicians to disagree with their clinical supervisors in anyway. When two clinicians are working with a student, conflicting opinions often arise. It is the job of the graduate clinician to adhered to their supervisor’s guidance and plan at all times. Upon graduation and when you have your CCCs then you can make your own freestanding clinician opinions.
Note - Names have been changed.