By Professor Tony Attwood and Dr Michelle Garnett
There is considerable research which confirms that a high level of psychiatric conditions co-occur with autism, for example, Lever & Guerts (2016) found a co-occurrence rate of up to 79% and the majority of autistic individuals experience at least one co-occurring mental health condition (Lai et al 2019). Rates of anxiety and affective disorders, eating disorders, psychosis and traumatic stress are higher in autistic individuals than in non-autistic individuals (Hossain et al 2020) The therapy with the greatest empirical evidence for success in the treatment of psychiatric conditions, including anxiety disorders, depression, addiction and eating disorders to name a few, is cognitive behaviour therapy (CBT), but what is CBT and is CBT helpful for autistic adults who are experiencing mental health conditions? In this two-part blog, we firstly define CBT and examine its effectiveness as a therapy for autistic adults. In part two we describe important modifications to CBT which can be helpful when treating autistic adults who experience mental health conditions. Our recommendations are based on our extensive clinical experience and current empirical research.
The origins of CBT
In the 1930s psychologists began to explore aspects of behaviour and learning and Behaviour Therapy (BT) subsequently emerged as a reaction to psychoanalysis by focussing on how external events shape observable behaviour. In the late 1960s, BT included operant conditioning based on identifying the consequences of behaviour such as reinforcement and punishment. Operant conditioning and the functional analysis of behaviour became the basis of Applied Behaviour Analysis, which has many adaptations, including as an early intervention for autistic children.
CBT evolved from BT in the 1970s with the addition of cognitive theory and social learning theory . Cognitive theory emphasises the importance of information processing, including the role of memory and attention, and cognitive or thinking distortions. Social learning theory extended behavioural principles to include that we learn vicariously, by watching and imitating others. CBT accommodates aspects of a person’s cognitive interpretation and processing of events, as well as their capacity to learn by watching others. A central principle of the “C” in CBT is that cognition and social learning mediate the relationship between life stress and psychopathology. Rigid and distorted beliefs about oneself, the world, and/or the future are explored and modified with CBT. In addition, CBT embraces learning by watching others, role-playing and skill rehearsal. The following definition of CBT from the American Psychological Association (APA, 2022) is helpful:
CBT is based on several core principles, including:
- Psychological problems are based, in part, on faulty or unhelpful ways of thinking.
- Psychological problems are based, in part, on learned patterns of unhelpful behaviour.
- People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives.
CBT treatment usually involves efforts to change thinking patterns. These strategies might include:
- Learning to recognize one’s distortions in thinking that are creating problems, and then re-evaluate them in light of reality.
- Gaining a better understanding of the behaviour and motivation of others.
- Using problem-solving skills to cope with difficult situations.
- Learning to develop a greater sense of confidence in one’s abilities.
CBT treatment also usually involves efforts to change behavioural patterns. These strategies might include:
- Facing one’s fears instead of avoiding them.
- Using role-playing to prepare for potentially problematic interactions with others.
- Learning to calm one’s mind and relax one’s body.
Rational for CBT and autism
CBT has direct applicability to autistic children, adolescents and adults who are recognised as experiencing significant difficulties in understanding, expressing, and managing emotions (Attwood 2007) and who, due to impaired Theory of Mind abilities, can make false assumptions as to the intentions and emotions of others (Baron-Cohen 2001). The therapeutic approach of CBT is to encourage the autistic person to be more consciously aware of their internal emotional state, their thinking and behavioural patterns and their bodily sensations or interoception. Recent research has confirmed that autism is associated with impaired interoception abilities (Suzman et al 2021).
CBT includes learning about and improving one’s ability to respond effectively to life situations, including social situations, transitions, highly stressful learning environments etc. These life circumstances, and others, commonly cause anxiety and stress for autistic adults, leading to problems coping with strong emotions such as fear, worry, anger and depression. CBT includes improving self-reflection and reflecting on the thoughts and feelings of self and others. Both of these skills are necessary for emotion management and are particularly difficult for autistic individuals who, due to their different neurology, tend to have a limited repertoire of responses to emotional arousal (Attwood 2007). Within CBT there is an opportunity to learn new skills to relax the autonomic nervous system and cope with social situations and other stressful life circumstances. Thus, CBT provides an opportunity to learn self-awareness and new strategies to manage, and in many cases overcome, mental health conditions.
Confirmation of the efficacy of CBT with autistic clients
Several studies have reviewed CBT as a treatment for autistic children (Perihan et al 2020; Selles et al 2015; Vasa et al 2014) and adults (Spain et al 2015) and found that over 70% of study participants responded positively to treatment, consistent with the expected response for the non-autistic population. A meta-analysis of 48 studies of CBT with autistic children and adults confirmed that CBT is effective using informant and clinician report measures (Weston, Hodgekins and Langdon 2016).
Our clinical experience has suggested that the effectiveness of CBT can be improved by recognising that a client may take some time to understand the concept of cognitive restructuring with more practice sessions required. There will probably be a need to increase the number of sessions from the conventional ten-session therapy to at least 20 sessions (Spain et al 2015). The efficacy of CBT will be enhanced by encouraging belief in the client’s ability to regulate their emotions (Sharma et al 2014) and more experiential activities and increasing compliance with homework tasks.
CBT has been successfully applied to treat adult autistic clients who are anxious (Ung et al 2015) depressed (Attwood and Garnett 2016) and autistic children who have experienced trauma (Stack and Lucyshyn 2019).
New developments in CBT
CBT is constantly evolving and adapting to research and clinical experience, and discovering new applications. The new developments include Mindfulness-Based Cognitive Therapy (MBCT) as well as Acceptance and Commitment Therapy (ACT) Dialectical Behaviour Therapy (DBT) and Cognitive Remediation Therapy (CRT). CRT has been suggested as a modality to increase cognitive flexibility (Stark et al 2021) in autistic clients. Modern technology is being used in incorporating CBT principles in popular computer games such as Minecraft in the new interactive CBT game Legend Land (2022).
A Note on Autistic Burnout
We are increasingly recognising the potential for autistic burnout when demands exceed coping abilities or burnout as a response to stressful life events and long-term camouflaging (Higgins et al 2021; Mantzalas et al 2021). Recovery is protracted and may last months or years. Burnout affects mental health, energy levels and cognitive abilities. According to Higgins et al (2021), the degree of cognitive confusion and overload associated with autistic burnout could limit the effectiveness of conventional CBT. For example, many clinicians may treat depression using the traditional CBT methods of behavioural activation and increasing social contact. Both these methods are likely to increase burnout leading to a worsening of symptoms. Utilising cognitive restructuring may increase rumination and “analysis paralysis.” We are finding that modifying CBT to include skills training for the school and workplace to provide modifications including decreasing responsibilities and creating a more autism-friendly culture are more helpful than conventional CBT strategies. This may include consideration of part-time employment, and a review of career options and strategies to reduce stress and increase energy such as Energy Accounting (Attwood & Garnett 2016). There will also need to be consideration of attitude changes by educating work colleagues and line managers about the daily challenges faced by an autistic employee about coping with changes in work schedules and expectations, sensory experiences and social engagement (Garnett & Attwood 2022). Other recommended strategies for autistic burnout include connecting with others who have shared the same experiences and arranging more time to engage in their special interest.
Our clinical experience has indicated that emotion regulation and a positive sense of self have been achieved by greater self-compassion and self-acceptance, such as the comment “I can look back now and cut myself a bit of slack” CBT can include activities to celebrate the qualities associated with autism with a positive outlook encouraging greater resilience in coping with situations associated with distress and agitation.
Where to from here?
On 7th and 8th September later this year, we will be conducting a live two-day Masterclass:
Day 1 will focus on assessing and confirming autism using a range of instruments based on research studies and our extensive clinical experience. Day 2 will focus on the reasons for problems with emotion perception, expression, and regulation for autistic adults, how to adapt therapy to maximise therapeutic effectiveness for autistic adults and learn strategies to develop a positive self-identity.
Professionals can choose to attend live in Sydney, Australia, or via live webcast. The recorded training will be available for participants to view for 60 days after the event.
Gaus, V. (2019) Cognitive-Behavioral Therapy for Adults with Autism Spectrum Disorder, second edition The Guilford Press.
Scarpa, Williams White and Attwood (2013) CBT for Children and Adolescents with High-Functioning Autism Spectrum Disorders The Guilford Press
Attwood, T. (2007) The Complete Guide to Asperger’s Syndrome London, Jessica Kingsley Publishers
Attwood and Garnett (2016) Exploring Depression and Beating the Blues: A CBT Self-Help Guide to Understanding and Coping with Depression in Asperger’s Syndrome [ASD-Level 1] Jessica Kingsley Publishers
APA (2022). Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults; https://www.apa.org/ptsd-guideline
Baron-Cohen S. (2001) Theory of Mind and autism: A review. In. L.M. Glidden (Ed.) International review of research in mental retardation: Autism (pp.169-184). San Diego, CA: Academic.
Garnett and Attwood (2022) Autism Working: A seven-stage plan for thriving at work Jessica Kingsley Publishers
Higgins et al (2021) Autism 25, 2356-2369
Hossain et al (2020) Psychiatry Research 287, 112922
Lai et al (2019) The Lancet Psychiatry 6 (10), 819-829
Lever, A.G., Geurts, H.M. Psychiatric Co-occurring Symptoms and Disorders in Young, Middle-Aged, and Older Adults with Autism Spectrum Disorder. J Autism Dev Disord 46, 1916–1930 (2016). https://doi.org/10.1007/s10803-016-2722-8
Legend Land (2022), www.fullpotentialpsychology.com.au
Mantzalas et al (2021) Autism in Adulthood
Perihan et al (2020) Journal of Autism and Developmental Disorders 58, 1958-1972
Selles et al (2015) Child Psychiatry and Human Development 46, 533-547
Sharma et al (2014) Autism 18, 244-254
Spain et al (2015) Research in ASD 9
Stack and Lucyshyn (2019) Journal of Autism and Developmental Disorders 49 1613-1625
Suzman et al (2021) Molecular Autism 12:42
Ung et al (2015) Child Psychiatry and Human Development 46, 533-547
Vasa et al (2014) Journal of Autism and Developmental Disorders 44
Weston, Hodgekins and Langdon (2016) Clinical Psychology Review 49, 41-54