Cognitive-Behavior Therapy
for Adults with Asperger's
Syndrome and HighFunctioning Autism
Valerie Gaus, Ph.D.
gaus@optonline.net
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
ASPERGER SYNDROME AS
A SOCIAL-COGNITIVE
DISABILITY
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
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
PROCESSING
OUTPUT
Brain receives
input from sense
organs and
filters out
irrelevant data;
also called
“perception”
Brain sorts,
organizes, stores,
compares,
categorizes,
foresees, plans,
formulates
using the
incoming
information
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 ASPERGER SYNDROME
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 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)
INPUT AND OUTPUT IN A SOCIAL
SITUATION
From 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 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
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)
Interrelationship Between Core
Deficits in Information Processing
Information About Self
Core
Information
Processing
Disorder
Information
About
Others
Non-social
Information
SOCIAL-COGNITIVE DISABILITY
AS A RISK FACTOR FOR COMORBID 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
SELF
MANAGEMENT
“Social Skill
Deficits”
Deficits in Activities
of Daily Living
SOCIAL
CONSEQUENCES
DAILY LIVING
CONSEQUENCES
Poor
Social
Support
Chronic
Stress
ANXIETY
DEPRESSIO
N
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
Environmental
Event
Behavioral
Response
Cognitive
Activity
Behavioral
Response
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
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 ->
New job
->
AUTOMATIC THOUGHT ->
I will never learn all of this
Emotion
->
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
ABC Model
(Based on Ellis)
A
ACTIVATING EVENT
B
BELIEF (IRRATIONAL)
C
CONSEQUENCE
(EMOTIONAL)
Someone said
something at work that
reminded me of when I
was beat up in school.
I was helpless then so I
will always be helpless.
I cannot cope with
anything
My sister criticized me
today.
I must be accepted and
Guilt, shame
praised by everyone all
of the time, or I am a bad
person.
Fear, anxiety
ABC Model: Restructuring “B”
A
B
C
ACTIVATING EVENT
BELIEF (RATIONAL
SUBSTITUTE)
CONSEQUENCE
(EMOTIONAL)
Someone said
something at work that
reminded me of when I
was beat up in school.
I felt helpless then but I
am helping myself now.
I can continue to help
myself in many ways.
My sister criticized me
today.
Sometimes I do things
Mild disappointment
well and sometimes not.
I am not perfect. Nobody
is. I can do the best I
can and my sister may
not always see that.
Momentary mild anxiety
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
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 living
independently.
I am not capable and
do not deserve the
chance to live
independently.
I am just another
disabled person,
a nut.
Disabled people are
a drain on the taxpayers.
I am not worthy of
taking money from
the taxpayers.
Everyone would be
better off without me.
I deserve to be
thrown out of my
apartment.
They will probably
throw me out within
the week.
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
Thoughts - things
we say silently to
ourselves.
Spoken words - things
we say out loud.
Comic Strip Conversations
Symbol for “Listen”
Comic Strip Conversations
“What would you like him to hear?”
Comic Strip Conversations
“What would you like to hear from him?”
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)
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
ASSERTIVENESS SKILLS
TRAINING

Talk Blocks (Innovative Interactions,
2000)*
I FEEL
frustrated
I NEED
to be listened to
* www.talkblocks.com
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)
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.
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.