Cognitive-Behavior Therapy for Adults with Asperger's Syndrome

Cognitive-Behavior Therapy Cognitive-Behavior Therapy for Adults with Asperger's for Adults with Asperger's

Syndrome and High-Syndrome and High-Functioning AutismFunctioning Autism

Valerie Gaus, Ph.D.

[email protected]

631-692-9750

QUESTIONS TO BE ADDRESSED QUESTIONS TO BE ADDRESSED TODAYTODAY

What are the unique challenges faced by adults with Asperger’s Disorder and their families?

What are the typical presenting problems leading adults to seek psychotherapy services?

What are the multiple social-cognitive factors maintaining the presenting problems?

What is cognitive-behavior therapy and why use it for these problems?

How can a therapist design an individualized plan for treating the presenting problems?

DISADVANTAGES FACED BY DISADVANTAGES FACED BY ADULTS WITH ASDADULTS WITH ASD

Diagnostic categories are continually shifting (e.g., Asperger’s Disorder not officially recognized in the United States until 1994).

Early needs were not recognized or were incorrectly labeled, so individuals did not receive specialized training, education or treatment.

Individuals report being distressed by knowledge that they were not “fitting in”, but not knowing why

In adulthood individuals are receiving inadequate or inappropriate supports and services.

Unemployed or underemployed: working far below potential

COMMON TRIGGERS FOR COMMON TRIGGERS FOR REFERRAL TO MENTAL HEALTH REFERRAL TO MENTAL HEALTH

TREATMENTTREATMENT

exposure to a traumatic event death of a loved one life stage transition stress (demands exceed coping capacity)

– work or day program– family or residence– peers

PRESENTING PROBLEMS FOR PRESENTING PROBLEMS FOR PSYCHOTHERAPYPSYCHOTHERAPY

anxiety depression loneliness “social skill deficits” problems with employment/school problems with dating poor judgment poor problem-solving ability

ASPERGER SYNDROME AS ASPERGER SYNDROME AS A SOCIAL-COGNITIVE A SOCIAL-COGNITIVE

DISABILITYDISABILITY

SOCIAL FEATURESSOCIAL FEATURES

Odd-sounding speech (overly precise of pedantic)

One-sided conversations; little or no interest in what others have to say

Preoccupation with specific topics; may not be able to talk about other subjects

Motor clumsiness Facial grimaces or tics Odd hand gestures or body movements Intrusiveness or difficulty recognizing

social boundaries

COGNITIVE FEATURESCOGNITIVE FEATURES

Rigid style of thinking Literal interpretation of language Driven by rules “All or nothing” thinking Difficulty modulating emotions “Catastrophizing” Difficulty perceiving or responding to

social cues, especially non-verbal Difficulty empathizing or taking another

person’s perspective

ASPERGER SYNDROME AS A ASPERGER SYNDROME AS A SOCIAL-COGNITIVE DISABILITYSOCIAL-COGNITIVE DISABILITY

Social Factors: Behavior leads to recurrent experiences of social rejection and ridicule, as well as disorganization and problems with task management and self-direction

Cognitive Factors: Idiosyncratic processing of information in several domains

COGNITIVECOGNITIVE FUNCTION FUNCTION

INPUT

Brain receives input from sense

organs andfilters out

irrelevant data;also called

“perception”

PROCESSING

Brain sorts,organizes, stores,

compares,categorizes,

foresees, plans,formulatesusing the incoming

information

OUTPUT

Brain controlsand producesoutput as a

verbal statementor other behaviorthat is hopefully

an adaptiveresponse tothe original

input

COGNITIVE DYSFUNCTONCOGNITIVE DYSFUNCTON

Cognitive deficits: Information processing operations that are missing or working poorly

Cognitive distortions: Errors in interpretation that involve faulty content of thoughts and can be associated with changes in mood and behavior

COGNITIVE DEFICITSCOGNITIVE DEFICITS

INPUT

– Problems with sensory perception– Inability to filter out irrelevant stimuli– Problems attending to relevant stimuli


PROCESSING

– Incorrect labeling or categorizing stimuli– Poor memory capacity or retrieval– Slow processing speed– Problems following a sequence– Problems comparing information– Problems with foresight or planning– Inability to use internal language or “self-talk”


OUTPUT

– Inability or poor use of language– Poor motor skills– Problems withholding output until processing

is complete (impulsivity)

COGNITIVE DISTORTIONSCOGNITIVE DISTORTIONS

Distorting the MAGNITUDE of a situation

– Catastrophizing– Overgeneralizing – Dichotomous thinking (“black and white” or

“all or nothing” thinking)


Making the wrong ATTRIBUTION for a situation

– Assuming the wrong intent for another person’s actions

– Assuming the wrong locus of control in a given event


Holding unrealistic EXPECTATIONS for a given situation

– Expecting self to be perfect – Pessimism: expecting things to always go

wrong

COGNITIVE DYSFUNCTION COGNITIVE DYSFUNCTION IN ASPERGER SYNDROMEIN ASPERGER SYNDROME

COGNITIVE DYSFUNCTION IN AS:COGNITIVE DYSFUNCTION IN AS:Maladaptive Processing of Three Maladaptive Processing of Three

Types of InformationTypes of Information

Information about others

Information about self

Non-social information

Dysfunctional Processing of Dysfunctional Processing of Information about OTHERS: Information about OTHERS:

“Social Cognition”“Social Cognition”

SOCIAL COGNITIONSOCIAL COGNITIONGeneral DefinitionGeneral Definition

The study of how people process and utilize information in social situations

“Social cognition is the study of how people make sense of other people and themselves.” (Fiske & Taylor, 1984)

INPUT AND OUTPUT IN A SOCIAL INPUT AND OUTPUT IN A SOCIAL SITUATIONSITUATION

From Gottman, Notarius, Gonso & Markman (1976)From Gottman, Notarius, Gonso & Markman (1976)

SOCIAL COGNITIONSOCIAL COGNITION

1) Analyze information coming from other people concerning their thoughts and feelings.

2) Generate expectancies about the overt behavior of others.

3) Draw inferences about the requirements of the social situation; how to behave in response.

HowHow do people make such inferences? They must do people make such inferences? They must be able to be able to extract meaningextract meaning from: from:

The general physical context of the interaction

The nature of the social situation

The speech of the other person

The body postures of the other person

The facial expressions of the other person

Dysfunctional Processing of Dysfunctional Processing of Information about OTHERSInformation about OTHERS

Theory of mind (Baron-Cohen, Leslie & Frith, 1985)

Attending to and using social cues (Klin, Jones, Shultz, Volkmar & Cohen, 2002)

Receptive language pragmatics (Twatchman-Cullen, 1998)

Dysfunctional Processing of Dysfunctional Processing of Information about SELFInformation about SELF

Perception and regulation of arousal states (emotion) (Marans, Rubin & Laurent, 2005; Berthoz & Hill, 2005)

Perception and regulation of sensory-motor experience (Baranek, Parham & Bodfish, 2005)

Dysfunctional Processing of Dysfunctional Processing of Information about NON-SOCIAL Information about NON-SOCIAL

EnvironmentEnvironment

Executive Functions (Ozonoff, South & Provencal, 2005)

• Planning & goal-setting • Organizing • Shifting sets and/or flexibility

Central Coherence (Happé, 2005)

Interrelationship Between Core Interrelationship Between Core Deficits in Information ProcessingDeficits in Information Processing

Non-social Information

InformationAboutOthers

Information About Self

Core

InformationProcessing

Disorder

SOCIAL-COGNITIVE DISABILITY SOCIAL-COGNITIVE DISABILITY AS A RISK FACTOR FOR CO-AS A RISK FACTOR FOR CO-

MORBID MENTAL HEALTH MORBID MENTAL HEALTH PROBLEMSPROBLEMS

Poor Social Support

Chronic Stress

ANXIETYDEPRESSION

CORE PROBLEM PROCESSINGINFORMATION

ABOUT OTHERS

CORE PROBLEM PROCESSINGINFORMATIONABOUT SELF

CORE PROBLEM PROCESSINGNON-SOCIAL INFORMATION

BEHAVIORAL DIFFERENCES

“Social Skill Deficits”

SELFMANAGEMENT

Deficits in Activities of Daily Living

SOCIAL CONSEQUENCES

DAILY LIVING CONSEQUENCES

Poor Social

Support

Chronic Stress

HOW CAN A THERAPIST HELP HOW CAN A THERAPIST HELP ANYANY PERSON STRUGGLING WITH PERSON STRUGGLING WITH

ANXIETY OR DEPRESSION?ANXIETY OR DEPRESSION?

RATIONALE FOR USE OF RATIONALE FOR USE OF COGNITIVE-BEHAVIOR THERAPYCOGNITIVE-BEHAVIOR THERAPY

Cognitive-behavior therapy was developed >40 years ago to address cognitive dysfunction in non-disabled people with mental health problems. In the years since then, there have been countless randomized controlled studies providing evidence for the utility of CBT to treat a variety of mental health problems in typical people (see Butler, Chapman, Forman & Beck, 2006)

CBT HistoryCBT History 1962 Ellis writes about “reason” in

psychotherapy 1963 Beck introduces cognitive hypotheses for

depression 1971 Meichenbaum and Goodman introduce

self-instructional strategies

D’Zurilla and Goldfried introduce problem

solving therapy 1973 Ellis introduces Rational-Emotive Therapy 1976 Beck publishes Cognitive Therapy and the

Emotional Disorders

BASIC ASSUMPTIONS OF COGNITIVE BASIC ASSUMPTIONS OF COGNITIVE BEHAVIORAL THERAPY (CBT)BEHAVIORAL THERAPY (CBT)

Cognitive activity (thoughts) affects behavior and emotions.

Cognitive activity may be monitored and altered.

Desired behavior change may be affected through cognitive change.

How is CBT similar to traditional How is CBT similar to traditional behavior therapy?behavior therapy?

Both assume problems can be addressed by teaching people ways to change behavior

Both assess outcome in measurable terms

How is CBT different than How is CBT different than traditional behavior therapy?traditional behavior therapy?

Differ in the view of HOW behavior may change

Traditional behavioral approach assumes behavior is shaped by the environment - the link between behavior and environment is direct

CBT takes into account the environment, but assumes that behavior change is mediated by cognitive change; there is a less direct link between environment and behavior

EnvironmentalEvent

BehavioralResponse

BehavioralResponse

EnvironmentalEvent Cognitive

Activity

RATIONALE FOR USE OF RATIONALE FOR USE OF COGNITIVE-BEHAVIOR THERAPY COGNITIVE-BEHAVIOR THERAPY

FOR ASPERGER SYNDROMEFOR ASPERGER SYNDROME

Presenting problems in people with Asperger Syndrome are often maintained by cognitive and social factors.

WHY HAS CBT NOT BEEN WHY HAS CBT NOT BEEN APPLIED TO THE APPLIED TO THE POPULATIONPOPULATIONMOST AT RISK FORMOST AT RISK FORCOGNITIVE PROBLEMS?COGNITIVE PROBLEMS?

ASSESSMENTASSESSMENT

ASSESSMENTASSESSMENT Explore multiple factors (Gardner & Sovner,

1994). Is the presenting problem being maintained by….

medical factors?psychiatric factors?environmental factors?social factors?cognitive factors?

ASSESSMENT OF ASSESSMENT OF COGNITIVE FACTORSCOGNITIVE FACTORS

What cognitive What cognitive deficitsdeficits are maintaining my are maintaining my client’s problem? Therefore, what skills client’s problem? Therefore, what skills might I teach my client?might I teach my client?

What cognitive What cognitive distortionsdistortions are maintaining are maintaining my client’s problem? Therefore, what my client’s problem? Therefore, what maladaptive thoughts and beliefs can be maladaptive thoughts and beliefs can be targeted and replaced to alleviate distress?targeted and replaced to alleviate distress?

COGNITIVE MODELCOGNITIVE MODEL (From (From Cognitive Therapy: Basics and BeyondCognitive Therapy: Basics and Beyond, Judith S. Beck, 1995), Judith S. Beck, 1995)

CORE BELIEF

INTERMEDIATE BELIEF

Situation -> AUTOMATIC THOUGHT -> Emotion

CORE BELIEFI am stupid.

INTERMEDIATE BELIEFIf I don’t understand something the first time I try, it shows

I can’t learn.

Situation -> AUTOMATIC THOUGHT -> EmotionNew job -> I will never learn all of this -> Anxiety

ASSESSMENTASSESSMENT Use of questions to elicit maladaptive

beliefs

Socratic questioning

Downward arrow techniques

COGNITIVE RESTRUCTURINGCOGNITIVE RESTRUCTURING

Based on Ellis (1962, 1973) and Beck (1976).

Variety of methods which teach how to recognize maladaptive beliefs how to challenge maladaptive beliefs how to replace maladaptive beliefs with more

adaptive ones

ABC ModelABC Model(Based on Ellis)(Based on Ellis)

AAAACCTTIIVVAATTIINNGG EEVVEENNTT

BBBBEELLIIEEFF ((IIRRRRAATTIIOONNAALL))

CCCCOONNSSEEQQUUEENNCCEE

((EEMMOOTTIIOONNAALL))

Someone saidsomething at work thatreminded me of when Iwas beat up in school.

I was helpless then so Iwill always be helpless.I cannot cope withanything

Fear, anxiety

My sister criticized metoday.

I must be accepted andpraised by everyone allof the time, or I am a badperson.

Guilt, shame

ABC Model: Restructuring “B”ABC Model: Restructuring “B”

AACTIVATING EVENT

BBBBEELLIIEEFF ((RRAATTIIOONNAALL

SSUUBBSSTTIITTUUTTEE))

CCONSEQUENCE

(EMOTIONAL)

Someone saidsomething at work thatreminded me of when Iwas beat up in school.

I felt helpless then but Iam helping myself now.I can continue to helpmyself in many ways.

Momentary mild anxiety

My sister criticized metoday.

Sometimes I do thingswell and sometimes not.I am not perfect. Nobodyis. I can do the best Ican and my sister maynot always see that.

Mild disappointment

COGNITIVE RESTRUCTURING COGNITIVE RESTRUCTURING METHODS FOR PEOPLE WITH ASDMETHODS FOR PEOPLE WITH ASD

The Thought Chain

Social Stories (Carol Gray, 1995)

Comic Strip Conversations (Carol Gray, 1994)

THE THOUGHT CHAINGaus, 2000

My roommate asked me to clean up crumbs

from the counter top.

I will be homeless, soon!

My roommate asked me to clean up crumbs from

the counter top.

Soon I will be homeless.

My roommate asked me to clean up crumbs from

the counter top.

Leaving crumbs is a sloppy act.

If I can’t clean up crumbs, I must be a slob.

A slob-pig is not capable of livingindependently.

They will probably throw me out within

the week.

I deserve to bethrown out of my

apartment.

Everyone would be better off without me.

I am not worthy oftaking money from

the taxpayers.

Disabled people area drain on the taxpayers.

I am just anotherdisabled person,

a nut.

I am not capable anddo not deserve the

chance to liveindependently.

Soon I will be homeless.

SOCIAL STORIES

My name is Julie. I see Dr. Gaus in therapy every week.

Today I am going to see her in a new place

I might get to the clinic early.

I get nervous when I have to wait. I also get bored if I have to wait.

I feel better if I eat a snack or candy

Sometimes there is candy in waiting rooms.

Candy that is displayed in a dish on the coffee table or counter is for people to take. This is “public food.”

Candy that is not displayed publicly on the coffee table or counter is “private food”.

People keep “private food” in their drawers, cabinets, pockets or purses.

People feel offended when they are asked to give away their “private food”.

Sometimes when people feel offended, they hide those feelings.

I will bring a book with me. If I have to wait, I can read my book.

I will bring some Lifesavers in my purse. If I have to wait, I can eat some of my Lifesavers.

COMIC STRIP CONVERSATIONS

Spoken words - thingswe say out loud.

Thoughts - thingswe say silently to

ourselves.

Comic Strip Conversations Comic Strip Conversations Symbol for “Listen”Symbol for “Listen”

Comic Strip Conversations Comic Strip Conversations “What would you like him to hear?”“What would you like him to hear?”

Comic Strip Conversations Comic Strip Conversations “What would you like to hear from him?”“What would you like to hear from him?”

ASSERTIVENESS SKILLS ASSERTIVENESS SKILLS TRAININGTRAINING

Teach person to express needs and desires express anger in adaptive ways say “No” in adaptive ways state opinions and contradictions appropriately confront authority figures

Based on Bergman (1985)


One strategy for identifying needs is to use Talk Blocks (Innovative Interactions, 2000)*

helps individual to identify feelings but also identify separately what is he or she needs in order to cope with or solve problem

Identifying is prerequisite for expressing

* www.talkblocks.com


Talk Blocks (Innovative Interactions, 2000)*

I FEEL frustrated

I NEED to be listened to

* www.talkblocks.com


To teach expression of wants and needs, focus on “I” statements.

One useful tool is the “Use Your I’s” game (Western Psychological Services, 2002)


The “Use Your I’s” game (Western Psychological Services, 2002) promotes the following formula for an assertive statement:

I feel …..when …..because…..I want …..

I feel angry when you change my appointment without telling me because I am an adult and I want to make my own appointments, please.

GUIDELINES FOR USING CBT FOR GUIDELINES FOR USING CBT FOR PEOPLE WITH Asperger SyndromePEOPLE WITH Asperger Syndrome

Teach the individual how to recognize, challenge and slow down the process of maladaptive thought processes.

Teach the individual to more accurately “read” the behavior of others and to re-conceptualize social situations.

Teach concrete skills to increase ability to cope with stress.

Maintain a balance between the provision of structured activities and empathy in the sessions.

Use visual material to illustrate points, as they tend to learn more effectively from symbols and pictures, despite their verbal strengths.

Documents

Cognitive-Behavior Therapy for Adults with Asperger's Syndrome