Cognitive-Behavior Therapy for Adults with Asperger's Syndrome and High-Functioning Autism Valerie Gaus, Ph.D. email@example.com 631-692-9750
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?
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
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
PRESENTING PROBLEMS FOR PSYCHOTHERAPY • anxiety • depression • loneliness • “social skill deficits” • problems with employment/school • problems with dating • poor judgment • poor problem-solving ability
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 • Intrusivenessor difficulty recognizing social boundaries
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
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
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
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
COGNITIVE DEFICITS • INPUT • Problems with sensory perception • Inability to filter out irrelevant stimuli • Problems attending to relevant stimuli
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”
COGNITIVE DEFICITS • OUTPUT • Inability or poor use of language • Poor motor skills • Problems withholding output until processing is complete (impulsivity)
COGNITIVE DISTORTIONS • Distorting the MAGNITUDE of a situation • Catastrophizing • Overgeneralizing • Dichotomous thinking (“black and white” or “all or nothing” thinking)
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
COGNITIVE DISTORTIONS • Holding unrealistic EXPECTATIONS for a given situation • Expecting self to be perfect • Pessimism: expecting things to always go wrong
COGNITIVE DYSFUNCTION IN AS:Maladaptive Processing of Three Types of Information • Information about others • Information about self • Non-social information
Dysfunctional Processing of Information about OTHERS: “Social Cognition”
SOCIAL COGNITIONGeneral 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 SITUATIONFrom Gottman, Notarius, Gonso & Markman (1976)
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.
How do people make such inferences? They must be able to extract meaning from: • The general physical context of the interaction • The natureof 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 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)
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)
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)
Information About Self Core Information Processing Disorder Information About Others Non-social Information Interrelationship Between Core Deficits in Information Processing
SOCIAL-COGNITIVE DISABILITY AS A RISK FACTOR FOR CO-MORBID MENTAL HEALTH PROBLEMS • Poor Social Support • Chronic Stress
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 ANXIETY DEPRESSION
HOW CAN A THERAPIST HELP ANY PERSON STRUGGLING WITH ANXIETY OR DEPRESSION?
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)
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
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.
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
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
Environmental Event Behavioral Response Environmental Event Behavioral Response Cognitive Activity
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.
WHY HAS CBT NOT BEEN APPLIED TO THE POPULATION MOST AT RISK FOR COGNITIVE PROBLEMS?
ASSESSMENT • 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 COGNITIVE FACTORS • 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?
COGNITIVE MODEL(From Cognitive Therapy: Basics and Beyond, Judith S. Beck, 1995) CORE BELIEF INTERMEDIATE BELIEF Situation -> AUTOMATIC THOUGHT -> Emotion
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
ASSESSMENT • Use of questions to elicit maladaptive beliefs • Socratic questioning • Downward arrow techniques
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
COGNITIVE RESTRUCTURING METHODS FOR PEOPLE WITH ASD • The Thought Chain • Social Stories (Carol Gray, 1995) • Comic Strip Conversations (Carol Gray, 1994)
THE THOUGHT CHAIN Gaus, 2000