Therapeutic use of soap operas in autistic-spectrum disorders

‘Soap opera’ is a popular television genre that ‘invites the audience to... identify with characters’ ([Livingstone, 1990][1]). Storylines tend to be shaped by national and local culture, although they may feature a disproportionate number of unstable relationships and tragedies ([Liebes &


LY N D A B R E E N
Therapeutic use of soap operas in autistic-spectrum disorders 'Soap opera' is a popular television genre that 'invites the audience to . . . identify with characters' (Livingstone, 1990). Storylines tend to be shaped by national and local culture, although they may feature a disproportionate number of unstable relationships and tragedies (Liebes & Livingstone, 1998). Narratives evolve continually, allowing scriptwriters to incite viewer debate on myriad topical social issues, including mental illness (Reveley, 1997).
Social change attributable to television drama programmes has already been documented (Singhal & Obregon, 1999). In 1975, the first pro-social soap opera 'Ven Conmigo' was credited with a 63% rise in literacy rates in Mexico (Brown et al, 1989). Following the screening of a Tanzanian soap opera on family planning methods, a large field study demonstrated an impressive increase in the uptake of contraception (Rogers et al, 1999). This capacity for community change implies potential for individual change, a concept which might support the therapeutic use of soap opera material. Moreover, the enduring emphasis on inter-character relationships in soap operas might provide a resource for exploring emotions and relationships in a clinical setting. Their rich audio-visual medium and established public popularity might also motivate potential clients (Creswell, 2001).
Current evidence supporting the therapeutic use of soap operas is limited but they have been used effectively to encourage discussion, problem-solving and selfawareness in therapeutic groups (Falk-Kessler & Froschauer, 1978). Qualitative research supports the use of soap opera material in identity work with Asian adolescents (Barker, 1997). Dutch adolescent girls who watched a soap opera in which family conflicts were a central theme could relate the narratives to their own lives, discuss 'primordial life values' and reflect how they might have behaved in similar situations (De Bruin, 2001). Soap opera material has also been used effectively in cognitive skills training with an adolescent with learning disability (Creswell, 2001). A 'soap therapy' approach might be useful in children, including those with autisticspectrum disorders, where descriptions of adapted cognitive therapy are currently relatively uncommon. Since family discussion of favourite television programmes has already been suggested to enhance social learning in autistic-spectrum disorders (Williams & Wright, 2004), therapeutic application of soap opera material might be similarly useful.
There is an ongoing need for evidence-based methods of teaching emotional recognition and social skills to individuals with autistic-spectrum disorders. A key feature of autistic cognition is delayed development of 'theory of mind', the concept that these individuals struggle to understand the thoughts, emotions and plans of others (Baron-Cohen et al, 1985). Since they fail to grasp that others think differently, people with autisticspectrum disorders tend to encounter difficulties in relating to and anticipating the actions of others. Consequently, they may appear to be eccentric or selfcentred, which further compounds their potential social isolation. One method used to facilitate social awareness is the 'social story', whereby hypothetical scenarios focus discussion on perspectives and cognitions of the self and others (Gray, 1993). Specially commissioned film clips have also been used effectively, but this is expensive and time-consuming, particularly for individualised therapies. More current tools include interactive computer programs special articles (Baron-Cohen, 2002). The popularity and frequent broadcasting of soap operas might provide opportunities to develop therapeutic interventions without incurring a lot of time or expense.

Case study
A 14-year-old boy with autism was referred to Tier 3 child and adolescent mental health services by his community paediatrician 'to improve social skills'. The referral highlighted difficulties subsequent to the boy imitating peers at mainstream school. He presented as extremely anxious, with skin picking and hand-flapping. He tape-recorded all clinic sessions himself and communicated only by whispering to his mother or writing in his notebook. There was no spontaneous speech or eye contact with the therapist.
In an attempt to foster engagement, the therapist based clinical work on the boy's self-confessed enthusiasm for soap operas. This intervention was time-limited for six sessions and was used as an adjunct to the planned behavioural approach. Prior knowledge of the characters appeared to facilitate the tasks and work was tailored to the boy's favourite soaps, 'EastEnders' and 'Coronation Street'. Homework between sessions was to watch the soap operas, which were often tape-recorded by his mother, and to monitor the developing storylines. Based on similar work in an adolescent with learning disability (Creswell, 2001), the therapeutic plan was to explore a key character's situations in magazine pictures and recently broadcast episodes. More specifically, the work concentrated on the character's beliefs and feelings, as well as trying to predict likely consequences.
Magazine pictures were selected that depicted basic emotions -happiness, disgust, surprise, sadness, anger and fear (Ekman et al, 1972). The boy was asked to describe the emotions depicted and, for some pictures, to hypothesise possible thought processes by completing speech bubbles. Context was important; he found it easier to consider emotions of familiar characters and was more likely to successfully interpret those of unfamiliar characters if given a brief synopsis of the plot. Through monitoring of storylines, these predictions were either validated or refuted, prompting further reflection.
This boy could often become animated when discussing favourite characters, which were also easily recalled. His eye contact and spontaneous speech improved significantly and he tended only to flap his hands when discussing his favourite characters. He became more skilled at reflecting upon inter-character relationships and considering 'the morals of the story', a skill which might be tricky to learn using a more abstract discursive approach. The boy tended to drift towards dramatic sub-plots, perhaps reflecting a difficulty in processing the more intensely depicted main storylines.
The perceived shared interest with the therapist might have helped to foster a therapeutic alliance, which can be challenging in people with autism (Alvarez, 1992).
Since this boy had previously been isolated at home, his mother had a positive view of their new shared interest. It was unclear to what extent, if any, new skills were transferable to 'real life'. The boy's mother did, however, recount that school had noted improvements in his class participation and a significant reduction in his imitative behaviours. Consequently, he was discharged from child mental health services with mutual agreement of all parties.

Discussion
This paper describes the use of soap operas in the therapy of a boy with autism, but it is important to consider the dramatic content of the episodes discussed. Villani (2001) described an association between television watched and subsequent behaviour in children, with the potential to learn positive behaviours and skills as well as negative ones. Television programmes include many examples of pro-social behaviour that provide models for children to emulate (Rushton, 1979(Rushton, , 1982Gunter & McAleer, 1990). Correlations between viewing habits and pro-social behaviours are, however, weaker than those with anti-social behaviours. This might be because antisocial and aggressive behaviours are more readily learned than pro-social behaviours which tend to be more subtle (Gunter & McAleer, 1990). Character features, including gender, may further confound the relative influence on pro-social and anti-social behaviours (Gunter, 1998).
The soap operas discussed ('EastEnders' and 'Coronation Street') are broadcast before the 9 p.m. 'watershed' and must follow network guidelines on the portrayal of explicit violence, although there is implied violence on occasion. People with learning disability are more likely to imitate television characters than their peers owing to their tendency to experience social isolation, dependency on others and social failures (Baran, 1973). For similar reasons, the potential for imitative behaviours should be considered in people with autisticspectrum disorders and it is sensible that certain episodes of soap operas should be avoided. It is clearly important to be aware of future storylines that might be unsuitable for children. This is easily achieved by reading the summaries of individual episodes planned for the forthcoming fortnight. Controversial plots can be discussed with parents who are empowered to reserve censorship judgement. For example, episodes of 'Coronation Street' that portrayed a suicide attempt were withheld in the case described. Soap opera storylines are arguably more predictable than other television dramas because of the pervasive reporting of plot 'spoilers' in the tabloid press and magazines. The tendency to show users of mental health services in a negative light (Byrne, 2003) makes prior awareness of dramatic content important.
People with autistic-spectrum disorders can have difficulty in distinguishing fantasy from reality. This may be intensified by the tendency of scriptwriters to embellish reality in the name of drama and for some characters, such as 'Dirty Den' from 'EastEnders', to adopt pantomime-like qualities (Gadow et al, 1988). It is therefore important to discuss the differences between what is happening in the soap opera and the person's life by drawing clear boundaries between the two issues in the therapeutic setting. Watching soap operas does require a considered approach, which, without guidance and explanation, can prove difficult for those with autistic-spectrum disorder who may be literal and pedantic. The caricature of life and death -in particular the high rates of deaths resulting from external causesmay pose difficulties for this group (Crayford et al, 1997;Clement, 1998). The value of using soap operas in therapy must also be carefully balanced against the possible negative effects of excessive television viewing. Although encouraging children with autistic-spectrum disorder to watch television might seem to discourage social integration, the approach suggested typically involves around 90 min of prescribed television viewing per week. The national daily average viewing for 6-to 12-year-olds is 154 min (British Broadcasting Corporation, 2004).
It is also important to be mindful of the dramatic representation of religious faith, ethnicity, disability and mental illness, as negative representations might have an impact upon self-concept work (Creswell, 2001). However, scriptwriters tend to seek advice from lay and professional experts in an attempt to realistically portray sensitive issues (Reveley, 1997).

Conclusion
The case study outlines a novel therapeutic approach with a child with autism using adapted cognitive therapy to explore emotional recognition and social awareness. The popularity and accessibility of the emotionally rich medium of the soap opera provided a useful and enjoyable therapeutic tool for therapist and client. For those with autistic-spectrum disorder, there might be advantages of a therapist-led 'human' approach that might extend to a shared interest with peers over currently popular computerised techniques. However, caution is suggested, particularly censorship of unsuitable storylines and clear explanation of more wayward plots. This is an area for future study, which should also aim to assess the generalisability of the cognitive skills acquired and develop a manualised approach for those working within child and adolescent mental health teams. To summarise Dorr (1981), television may be an underused therapeutic resource and '[we] could certainly use it more to teach children to recognise emotions and to understand display rules'.

Declaration of interest
None.