My first introduction to autism was a rather jarring one. It was my first day on my child psychiatry rotation. The Department was in a house on the University Hospitals campus in Madison. As I approached the house I heard a very loud “thump! thump! thump! Sound, which literally rattled the rafters of the house.
Inside was a 12-year-old non-verbal, severely autistic girl banging her head on a school desk. She had a helmet on, but even that was not enough to muffle that awful sound.
It occurred to me then that somewhere inside that girl, troubled as she was, had to be some “island of intactness,” some uninjured element of reality and wellness, however hidden and deeply buried.
After my residency training I was given the responsibility of starting a Children’s Unit at Winnebago Mental Health Institute near Oshkosh, Wisconsin. There were nearly 800 patients at Winnebago at that time and about 25 of them were age 18 or younger. We gathered them together and started the unit. We hired a staff and started a school.
As I looked at those 25 patients, some severely affected, I was reminded of the girl with the helmet. It seemed to me then, as it does now many years later, that somewhere in these patients, often deeply hidden and buried, is that still uninjured “island of intactness.” Our task, and opportunity, is to find that hidden spark of wellness. Having discovered it, we need to tend it, love it nourish it, reward it, strengthen it and celebrate it. As we do that, the sliver of un-impairment expands and with it comes improved language, socialization and daily living skills. That results in more independence eventually.
Sometimes, although certainly not always, that bit of intactness is an “island of genius.” We call that savant syndrome and I have had the privilege of meeting a number of these extraordinary people. More often, the island of intactness is less spectacular, but nonetheless a valuable discovery.
There are a number of approaches to children with autism these days—Applied Behavioral Analysis (ABA); Son Rise; Rapid Prompting Method (RPM); Early Start Denver Model, to name a few. But embedded in all of them, in my view, is the same, corresponding search for, and then promotion of, the island of intactness. Those methods may use varying techniques—reward, play, relationship building, conversation, socialization, role playing etc.—but the goal of all of them is to discover, engage and grow that sliver toward recovery.
It is this search for strengths, however hidden, that results in progress in treating autistic children. But that same principle of a search for the island of intactness applies in many other conditions as well. In the patient with Alzheimer’s disease, for example, we look for preserved memory or skills. So often, traces of musical memory remain, or maybe card playing ability or drawing. We seize on those and tend them, reward them, and celebrate them as a hook into their intactness as a way of interacting still, preserving abilities and even seeing some progress in preserving memory. The same principle applies in the depressed or psychotic patients: we seek to find that bit of reality and health still present, and build on it just as we do with an autistic youngster.
The island of intactness is found in many forms. In one of my Winnebago patients it was the ability to put jigsaw puzzles together, picture side down, just from the shapes of the pieces. Another patient was fascinated with prime numbers and other types of mathematic problems. In a number of other patients, the Ipad has released a torrent of “talk,” betraying the myth that children who are mute have nothing to say.
There are many, many other well known examples.
For Owen Suskind, whose father, Ron, made the movie about him called Life, Animated, the island of intactness was his passion for Disney movies, which he memorized by the dozens.
Another man, Stephen Wiltshire can draw an entire city, building by building and window by window after a 45-minute helicopter ride. Mute as a child, his first word was “paper.” An observant teacher gave him a piece of paper and crayons and his island of intactness, once tapped, unleashed his lifelong astonishing drawing ability. Now he has his own gallery in London.
As a very young child, Leslie Lemke would pluck out rhythms and primitive tunes on his bedsprings; his mother, May, got him a little piano. Now he composes his own pieces.
Ping Lian Yeak went shopping one day with his father He had some ice cream in a brightly colored paper wrapper. When he got home Ping Lian Yeak studied intently and then reproduced the intricate coloring on the wrapper. His mother recognized that spark of talent, trained it and now Ping Lian Yeak has his own gallery in Malaysia and will exhibit at the Agora Gallery in New York City in March, 2017.
The reward, from the therapist or Mom or Dad, can be a “good job” compliment, a high five, a tummy tickle, a ride in a wagon or a tasty treat. Success breeds success and the journey of discovery, expansion and transition is on.
The search for the island of intactness should always focus on strengths and abilities, not deficits or disabilities. Strength based, individualized approaches, whatever the method or name, once the island of intactness is found, work well with a wide variety of persons whatever the particular condition underlying. Watching those islands of intactness broaden over time, as a conduit of actualization, can give a deep sense of satisfaction for the therapist, whatever the method. But more importantly the improvement can be source of deep relief, and hope, for the patient and family.