Autism spectrum disorder and CBT

Paragraph sentences: 4, 3, 2, 1, 4, 5 * Level five: Abstract; general, oriented toward a solution or conclusion * Level Four: Less general; orientated toward a problem; pulls ideas together * Level Three: Conceptual summary; draws together two or more pieces of evidence, or introduces a broad example. * Level Two: Description; plain or interpretive summary; establishing shot * Level One: Concrete; evidentiary; raw; unmediated data or information

Abstract

I usually find myself talking about the usefulness of cognitive behaviour therapy (CBT) in treating mental disorders, and my optimism is usually warranted. But CBT is not a panacea, and individuals with autism spectrum disorder (ASD) are systematically left out of treatment studies. This means that, for all its usefulness, we know close to nothing about the usefulness of CBT for individuals with ASD. Another consequence is that we leave it up to each individual therapist to adapt therapy, which is challenging for the therapist.

Other mental disorders are common in ASD

Individuals with ASD often experience co-occuring mental disorders, but we don’t know how to treat them effectively. Part of the problem is that individuals with ASD are excluded from treatment studies, so the evidence-base for CBT does not cover individuals with ASD. I don’t think the solution is to include individuals with ASD in all treatment studies, because standard CBT is less effective for individuals with ASD. Still, estimates of co-occuring mental disorders are high: 37% of individuals with ASD also have depression, 26% have generalised anxiety disorder, and over 20% have obsessive-compulsive disorder. Even though treatable mood and anxiety disorders are common in individuals with ASD, the standard CBT treatments that are typically used are less effective for autistic individuals. We need adapted treatments that take the difficulties related to ASD into account.

Autistic individuals struggle with social cognition

Autism spectrum disorder is characterised by difficulties in social communication, as well as restricted interests and repetitive behaviour. When researchers compare the cognitive functioning in adults with ASD to neurotypical adults, they find that adults with ASD show impairments in social cognition. Social cognition includes theory of mind–knowing that another individual can have other desires and beliefs than yourself–and emotion perception and processing (understanding emotional expressions in others). These difficulties make psychological therapy challenging for individuals with ASD.

Attending a therapy session involves meeting a new person, speaking with them about personal information, and building up a rapport over time, all processes which can be challenging for the autistic individual. - Cooper K, Loades ME, Russell A. Adapting psychological therapies for autism

Adapted CBT for ASD

Paragraph sentences: 4, 3, 2, 1, 4, 5 * Level five: Abstract; general, oriented toward a solution or conclusion * Level Four: Less general; orientated toward a problem; pulls ideas together * Level Three: Conceptual summary; draws together two or more pieces of evidence, or introduces a broad example. * Level Two: Description; plain or interpretive summary; establishing shot * Level One: Concrete; evidentiary; raw; unmediated data or information

4- Unfortunately, there is little research into adapted CBT for individuals with both ASD and a mood or anxiety disorder. 3- 2- 1- 4- 5- Unfortunately, there is little research into adapted cognitive behaviour therapy for individuals with both ASD and a mood or anxiety disorder. A recent overview found only two randomised studies, across all disorders!

Despite the scant evidence base, some practitioners have provided insights into useful strategies in CBT that they have used successfully in treatment.

Adaptations to CBT
Longer sessions
Taking breaks
Using a more directive approach
Avoiding metaphors and abstract concepts
Using images and written material
Adapting information to fit with the individual’s special interests
Practice in recognising, labelling, and rating the intensity of emotions
Involving family members and other support

Summary

But should we assume that cognitive behaviour therapy–which often involves confronting the trigger of your anxiety–is to be preferred for individuals with ASD, because it has been found to be effective for individuals without ASD? Of course not. That’s why we need more research into which therapies work, and which don’t.

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Oskar Flygare
PhD Student in psychology

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