Many of Dr. Amitta Shah's recommendations, in Catatonia, Shutdown and Breakdown in Autism, were not found anywhere else in my reading. Shah is very transparent that the book is designed for clinicians and caretakers; it is definitely not a DIY guide to recovering from autistic catatonia. Some autistic people may even find its language (including use of terms like "high-functioning") to be a bit off-putting. Nonetheless, I found it to be an invaluable read Shah is very direct about the challenges of living alone for those who might be recovering from catatonia; one of the strongest recommendations of this book might be for the person in burnout to find a way to get as much direct support as possible. She suggests that a great deal of support may be necessary for recovery, and that even one-on-one support might be necessary in the early stages of healing.

Many of Shah's recommendations for managing catatonia echo those provided by autistic people for managing autistic burnout. This is so both at the level of individual suggestions and at the level of broad themes. Both Shah and Raymaker's interviewees, for instance, emphasize the potential value of meditation. The studies of Shah and of Raymaker et al. are also united in recommending lots of support. They differ, however, in two major ways. First, while (as I am suggesting) the overlap between burnout and catatonia, the conditions are not the same, and catatonia is frequently much more severe, requiring much higher levels of support. Second, while the advice collected by Raymaker's study was directed toward autistic adults, Shah's advice is intended for those who support them.

Perhaps as a result of these functional differences, the recommendations of Shah and of Raymaker can sometimes diverge in important ways. In those cases, I typically found Shah's work to be counterintuitive and sometimes even corrective of my own approach to healing. One such case had to do with its attitude toward total rest. While this strategy is often necessary for healing, Shah also points out that the wrong kind of rest and immobility can actually make the problem of catatonia much worse, especially when it produces too much withdrawal and isolation. The divergence of Shah and Raymaker's advice may suggest that many of the strategies which are useful in states of mild autistic burnout can in fact become counterproductive, or even dangerous, in cases of catatonic burnout. 

Far from secluding themselves in order to rest until they are fully recovered, Shah suggests, the catatonic person should receive as much support as possible in order to help them maintain their day-to-day physical routines. In fact, much of the role of the one-on-one carer as envisioned in Dr. Shah's book is to help catatonic people to maintain as much of these daily routines as possible. She writes, 

“It is extremely important that the person should be given support, assistance, and as much help as they need to complete activities and to keep to their routine as much as possible. Although this seems obvious, parents and staff are often unsure as to how much help to give a person and how much to leave them to their own devices. I have come across very well-meaning parents, carers, or teachers who have left the individual to complete activities like eating, washing and dressing even if it is taking hours to complete. They, understandably, find it difficult to provide help and assistance to an individual who has been independent previously. I cannot emphasize enough how important it is to provide the help and support and to keep the person moving through their routine of activities throughout the day.”

Elsewhere as well, Shah cautions her readers against either a) too much passive rest or b) too much focus on independence and self-sufficiency. Instead, she proposes that people in catatonic breakdown might seek all necessary and possible support in order to continue going about their daily round, and especially to participate in their favorite activities, rather than be homebound as a result of their growing catatonia. She suggests that it is better for people in catatonic breakdown to travel to favorite places, in supported ways--for instance, by being driven, or even using a wheelchair as necessary--than simply to stay homebound. She suggests that caretakers

"[t]ry activities which are more physical, outdoors and active rather than table-top activities. Many autistic individuals find it therapeutic to spend time outdoors and connecting with nature and animals. Often, when someone develops catatonia-related breakdown, they become more housebound due to difficulties in walking and so on. This results in them being unable to pursue...

developed catatonia-related breakdown, she was unable to attend day services and enjoy the interaction with others and her favorite craft activities. She became housebound as she became increasingly fearful of going outdoors. Ria was also unable to enjoy nature and community activities which had previously brought her a lot of joy. Staff were advised to use any strategies possible to enable Ria to pursue nature and community activities. The main problem was Ria’s mobility due to muscle wasting and fear. Once this was made a priority, staff found various ways to transport Ria to places where she could engage in activities which gave her joy. This had a huge beneficial effect generally on Ria’s catatonia symptoms which decreased substantially and improved her quality of life.”

It's important that these physical routines should not necessarily require the catatonic person to speak or to process speech: “It is more important to relate to the individual through physical activities than through verbal discussions." At times, expecting too much spoken communication--especially around decision-making--can actually increase the pressure on the catatonic person, in a way that can lead to further deterioration. Prompting the catatonic person to act can often be extremely important in helping a suffering person go about their daily round, especially if they are prone to freeze or to get "stuck," but this prompting is often most effective when it takes the form of a gentle touch or a nonverbal form of signaling. She writes, for instance, that if the autistic person is "standing still and staring into space," an effective prompt might be "a light touch," rather than explicit verbal direction.

Significantly, while Shah is explicit about the risks of pressuring autistic people to speak or to relate to other primarily through speaking, she says very little about other forms of social performance such as masking, whereas autistic people themselves frequently put a very great degree of emphasis on masking as a factor in all forms of burnout. One might wonder whether masking is a factor in catatonia as well, and whether autistic patients who seem to mask might be encouraged to unmask, as by stimming freely, by feeling free or having "permission" to avoid eye contact even in social situations, or in whatever ways feel safe and comfortable to them. Some autistic people choose to wear a face mask, even when not at risk of respiratory illness, because it lessens some of the burden on them to manage their facial expressions. Many autistic people are hyperaware of the ways that they mask in social situations and might welcome a chance to discuss these masking strategies, with a goal of figuring out how to circumvent them in order to avoid or lessen burnout. 

In general, Dr. Shah emphasizes the importance of helping the autistic person maintain physical activity; relating to them through physical activity (rather than excessive verbal demands); and helping them stay connected to the things and places they most enjoy. She cautions the reader against over-emphasizing independence or self-sufficiency, as long as the person is suffering from catatonia. Instead, she suggests that the caretaker or helper should do whatever they can to help the sufferer maintain consistent, timely, fluid physical routines, and to maintain strong attachments to their favorite things in life.  The words "joy" and "favorite" emerge several times in Shah's work: the catatonic person should be directed toward activities and venues which have previously brought them maximal joy, and they should be provided with any assistance necessary to help them seek out their favorite things: favorite activities, favorite meals, favorite social settings. Shah even suggests that, where an autistic person's mobility prevents them from going out into nature or visiting favorite restaurants in the way that they ordinarily might, they should be supported in any way they can to make this visit safely. 

Dr. Shah's writing also does a lot to underscore the value of even silent companionship for those struggling with catatonia. She writes,

“Providing one-to-one support to the individual is effective and beneficial at various levels. It provides security and reassurance to the person that they will not be left in a ‘paralytic’ state (which must be very frightening and stressful in itself)." 

The traumatic and traumatizing aspects of catatonia are not always well understood, but it is my view any my experience that PTSD is a very likely outcome of autistic catatonia, especially among people who are not supported and who are accustomed to living independently.  Undiagnosed and untreated PTSD among sufferers of catatonia may also contribute to the risk of suicide, which is a documented risk of catatonia. 

An implication of Shah's advice is that autistic people in catatonic burnout might have to make peace with relying on others and even giving up some independence and self-determination for a short time--a sacrifice that can be very difficult for many of us to make, for a range of reasons both good and bad.  On reflection, I feel that Shah's recommendations--with their emphasis on giving and receiving support--offer those with lower support needs a chance to interrogate some of their own internalized ableism. Independence and self-sufficiency are sometimes treated as self-evidently valuable by those who write about autism. Yet valuing independence can be a way that people with minimal support needs aim--often subconsciously--to distinguish themselves from those with higher support needs, typically because of unexamined and internalized prejudice against more visibly disabled people. An excessive focus on "independence" can thus divide the autistic community along lines drawn by internalized ableism. These kinds of distinctions--and a subconscious drive, common among some autistic people, to differentiate themselves from those who need too much help, too much support--may not ultimately be the best foundation for autistic activism or autistic politics, since they exclude so many people for whom self-sufficiency is neither possible nor desirable. A politics of seeking and giving help might not only be the best for our community; it might also serve as the best basis for the recovery from burnout, especially burnout so profound that it has become catatonia.