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Cognitive-Behavior Therapy for Adults with Asperger's Syndrome and High- Functioning Autism Valerie Gaus, Ph.D. 631-692-9750.

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Presentation on theme: "Cognitive-Behavior Therapy for Adults with Asperger's Syndrome and High- Functioning Autism Valerie Gaus, Ph.D. 631-692-9750."— Presentation transcript:

1 Cognitive-Behavior Therapy for Adults with Asperger's Syndrome and High- Functioning Autism Valerie Gaus, Ph.D. gaus@optonline.net 631-692-9750

2 QUESTIONS TO BE ADDRESSED TODAY 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?

3 DISADVANTAGES FACED BY ADULTS 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

4 COMMON TRIGGERS FOR REFERRAL TO MENTAL HEALTH TREATMENT 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

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

6 ASPERGER SYNDROME AS A SOCIAL-COGNITIVE DISABILITY

7 SOCIAL 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

8 COGNITIVE 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

9 ASPERGER SYNDROME AS A SOCIAL-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

10 COGNITIVE FUNCTION INPUT Brain receives input from sense organs and filters out irrelevant data; also called “perception” PROCESSING Brain sorts, organizes, stores, compares, categorizes, foresees, plans, formulates using the incoming information OUTPUT Brain controls and produces output as a verbal statement or other behavior that is hopefully an adaptive response to the original input

11 COGNITIVE 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

12 COGNITIVE DEFICITS INPUT – Problems with sensory perception – Inability to filter out irrelevant stimuli – Problems attending to relevant stimuli

13 COGNITIVE DEFICITS 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”

14 COGNITIVE DEFICITS OUTPUT – Inability or poor use of language – Poor motor skills – Problems withholding output until processing is complete (impulsivity)

15 COGNITIVE DISTORTIONS Distorting the MAGNITUDE of a situation – Catastrophizing – Overgeneralizing – Dichotomous thinking (“black and white” or “all or nothing” thinking)

16 COGNITIVE DISTORTIONS 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

17 COGNITIVE DISTORTIONS Holding unrealistic EXPECTATIONS for a given situation – Expecting self to be perfect – Pessimism: expecting things to always go wrong

18 COGNITIVE DYSFUNCTION IN ASPERGER SYNDROME

19 COGNITIVE DYSFUNCTION IN AS: Maladaptive Processing of Three Types of Information Information about others Information about self Non-social information

20 Dysfunctional Processing of Information about OTHERS: “Social Cognition”

21 SOCIAL COGNITION General 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)

22 INPUT AND OUTPUT IN A SOCIAL SITUATION From Gottman, Notarius, Gonso & Markman (1976)

23 SOCIAL 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.

24 How do people make such inferences? They must be able to extract meaning 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

25 Dysfunctional Processing of Information 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)

26 Dysfunctional Processing of Information 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)

27 Dysfunctional Processing of Information about NON-SOCIAL Environment Executive Functions (Ozonoff, South & Provencal, 2005) Planning & goal-setting Organizing Shifting sets and/or flexibility Central Coherence (Happé, 2005)

28 Interrelationship Between Core Deficits in Information Processing Non-social Information Information About Others Information About Self Core Information Processing Disorder

29 SOCIAL-COGNITIVE DISABILITY AS A RISK FACTOR FOR CO- MORBID MENTAL HEALTH PROBLEMS Poor Social Support Chronic Stress

30 ANXIETY DEPRESSIO N CORE PROBLEM PROCESSING INFORMATION ABOUT OTHERS CORE PROBLEM PROCESSING INFORMATION ABOUT SELF CORE PROBLEM PROCESSING NON-SOCIAL INFORMATION BEHAVIORAL DIFFERENCES “Social Skill Deficits” SELF MANAGEMENT Deficits in Activities of Daily Living SOCIAL CONSEQUENCES DAILY LIVING CONSEQUENCES Poor Social Support Chronic Stress

31 HOW CAN A THERAPIST HELP ANY PERSON STRUGGLING WITH ANXIETY OR DEPRESSION?

32 RATIONALE FOR USE OF COGNITIVE-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)

33 CBT 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

34 BASIC ASSUMPTIONS OF COGNITIVE 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.

35 How is CBT similar to traditional behavior therapy? Both assume problems can be addressed by teaching people ways to change behavior Both assess outcome in measurable terms

36 How is CBT different than 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

37 Environmental Event Behavioral Response Behavioral Response Environmental Event Cognitive Activity

38 RATIONALE FOR USE OF COGNITIVE-BEHAVIOR THERAPY FOR ASPERGER SYNDROME Presenting problems in people with Asperger Syndrome are often maintained by cognitive and social factors.

39 WHY HAS CBT NOT BEEN APPLIED TO THE POPULATION MOST AT RISK FOR COGNITIVE PROBLEMS?

40 ASSESSMENT

41 ASSESSMENT Explore multiple factors (Gardner & Sovner, 1994). Is the presenting problem being maintained by…. medical factors? psychiatric factors? environmental factors? social factors? cognitive factors?

42 ASSESSMENT OF COGNITIVE FACTORS What cognitive deficits are maintaining my client’s problem? Therefore, what skills might I teach my client? What cognitive deficits are maintaining my client’s problem? Therefore, what skills might I teach my client? What cognitive distortions are maintaining my client’s problem? Therefore, what maladaptive thoughts and beliefs can be targeted and replaced to alleviate distress? What cognitive distortions are maintaining my client’s problem? Therefore, what maladaptive thoughts and beliefs can be targeted and replaced to alleviate distress?

43 COGNITIVE MODEL (From Cognitive Therapy: Basics and Beyond, Judith S. Beck, 1995) CORE BELIEF INTERMEDIATE BELIEF Situation -> AUTOMATIC THOUGHT -> Emotion

44 CORE BELIEF I am stupid. INTERMEDIATE BELIEF If I don’t understand something the first time I try, it shows I can’t learn. Situation -> AUTOMATIC THOUGHT -> Emotion New job -> I will never learn all of this -> Anxiety

45 ASSESSMENT Use of questions to elicit maladaptive beliefs Socratic questioning Downward arrow techniques

46 COGNITIVE 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

47 ABC Model (Based on Ellis)

48 ABC Model: Restructuring “B”

49 COGNITIVE RESTRUCTURING METHODS FOR PEOPLE WITH ASD The Thought Chain Social Stories (Carol Gray, 1995) Comic Strip Conversations (Carol Gray, 1994)

50 THE THOUGHT CHAIN Gaus, 2000

51 My roommate asked me to clean up crumbs from the counter top. I will be homeless, soon!

52

53 My roommate asked me to clean up crumbs from the counter top. Soon I will be homeless.

54 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 living independently. They will probably throw me out within the week. I deserve to be thrown out of my apartment. Everyone would be better off without me. I am not worthy of taking money from the taxpayers. Disabled people are a drain on the taxpayers. I am just another disabled person, a nut. I am not capable and do not deserve the chance to live independently. Soon I will be homeless.

55 SOCIAL STORIES

56 My name is Julie. I see Dr. Gaus in therapy every week. Today I am going to see her in a new place

57 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

58 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.”

59 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.

60 People feel offended when they are asked to give away their “private food”. Sometimes when people feel offended, they hide those feelings.

61 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.

62 COMIC STRIP CONVERSATIONS

63 Spoken words - things we say out loud. Thoughts - things we say silently to ourselves.

64 Comic Strip Conversations Symbol for “Listen”

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

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

67 ASSERTIVENESS SKILLS TRAINING 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)

68 ASSERTIVENESS SKILLS TRAINING 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

69 ASSERTIVENESS SKILLS TRAINING Talk Blocks (Innovative Interactions, 2000)* I FEEL frustrated I NEED to be listened to * www.talkblocks.com

70 ASSERTIVENESS SKILLS TRAINING 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)

71 ASSERTIVENESS SKILLS TRAINING 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.

72 GUIDELINES FOR USING CBT FOR PEOPLE 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.


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