Fact sheet on adults with Asperger's syndrome and Cognitive Behavioral Therapy


Adults on the autism spectrum can be prone to depression, anxiety, obsessive-compulsive disorders, bipolar disorders and other mental health issues. Cognitive behavioral therapy (CBT) is one of a range of treatment options. It is a psychotherapy based on modifying everyday thoughts and behaviors, with the aim of positively influencing emotions.


The general approach developed out of behavior modification and Cognitive Therapy, and has become widely used to treat mental disorders. The particular therapeutic techniques vary according to the particular kind of client or issue, but commonly include keeping a diary of significant events and associated feelings, thoughts and behaviors; questioning and testing assumptions or habits of thoughts that might be unhelpful and unrealistic; gradually facing activities which may have been avoided; and trying out new ways of behaving and reacting.


Relaxation and distraction techniques are also commonly included. Cognitive Behavioral Therapy is widely accepted as an evidence-based, cost-effective psychotherapy for many disorders. It is sometimes used with groups of people as well as individuals, and the techniques are also commonly adapted for self-help manuals and, increasingly, for self-help software packages.


The basics of Cognitive Behavioral Therapy

Cognitive Behavioral Therapy is based on the idea that how we think (cognition), how we feel (emotion) and how we act (behavior) all interact together. Specifically, our thoughts determine our feelings and our behavior. Therefore, negative - and unrealistic - thoughts can cause us distress and result in problems.


One example could be someone who, after making a mistake, thinks "I'm useless and can't do anything right." This impacts negatively on mood, making the person feel depressed; the problem may be worsened if the individual reacts by avoiding activities. As a result, a successful experience becomes more unlikely, which reinforces the original thought of being "useless."


In therapy, the latter example could be identified as a self-fulfilling prophecy or "problem cycle," and the efforts of the therapist and client would be directed at working together to change this. This is done by addressing the way the client thinks in response to similar situations and by developing more flexible thought patterns, along with reducing the avoidance of activities. If, as a result, the client escapes the negative thought pattern, the feelings of depression may be relieved. The client may then become more active, succeed more often, and further reduce feelings of depression.


Thoughts as the cause of emotions in CBT

With thoughts stipulated as being the cause of emotions rather than the outcome or by-product, cognitive therapists reverse the causal order more generally used by psychotherapists. Therefore, the therapy is to identify those irrational or maladaptive thoughts that lead to negative emotion and identify what it is about them that is irrational or just not helpful; this is done in an effort to reject the distorted thoughts and replace them with more realistic alternative thoughts, in a process sometimes referred to as cognitive-shifting.


Cognitive Behavioral Therapy is not an overnight process. Even after patients have learned to recognize when and where their thought processes go awry, it can take months of concerted effort to replace an irrational thought process or habit with a more reasonable, salutary one.


The cognitive model says that a person's core beliefs (often formed in childhood) contribute to 'automatic thoughts' that pop up in every day life in response to situations. Cognitive Therapy practitioners hold that clinical depression is typically associated with negatively biased thinking and irrational thoughts. Cognitive Behavioral Therapy is often used in conjunction with mood stabilizing medications to treat bipolar disorder.


Types of Cognitive Behavioral Therapy

Cognitive Behavioral Therapy can be seen as an umbrella term for many different therapies that share some common elements. While similar views of emotion have existed for millennia, the earliest form of Cognitive Behavior Therapy was developed by Albert Ellis in the early 1950s. Ellis eventually called his approach Rational Emotive Behavioral Therapy, or REBT, as a reaction against popular psychoanalytic and increasingly humanistic methods at the time. Aaron T. Beck independently developed another Cognitive Behavioral Therapy approach, called Cognitive Therapy, in the 1960s.


Cognitive Therapy rapidly became a favorite intervention to study in psychotherapy research in academic settings. In initial studies, it was often contrasted with behavioral treatments to see which was most effective. However, in recent years, cognitive and behavioral techniques have often been combined into cognitive behavioral treatment. This is arguably the primary type of psychological treatment being studied in research today.


Cognitive Behavioral Group Therapy (CBGT) is a similar approach in treating mental illnesses, based on the protocol by Richard Heimberg. In this case, clients participate in a group and recognize they are not alone in suffering from their problems.


A sub-field of Cognitive Behavior Therapy used to treat Obsessive compulsive disorder makes use of classical conditioning through extinction (a type of conditioning) and habituation. (The specific technique, Exposure with Response Prevention (ERP) has been demonstrated to be more effective than the use of medication--typically SSRIs--alone.) Cognitive Behavioral Therapy has also been successfully applied to the treatment of Generalized Anxiety Disorder , health anxiety, Social phobia and Panic Disorder. In recent years, Cognitive Behavioral Therapy has been used to treat symptoms of schizophrenia, such as delusions and hallucinations. This use has been developed in the UK by Douglas Turkington and David Kingdon.


Other types of Cognitive Behavioral Therapy include Dialectical Behavior Therapy, Self-Instructional Training, Schema-Focused Therapy and many others.


Cognitive Behavioral Therapy has a good evidence base in terms of its effectiveness in reducing symptoms and preventing relapse. It has been clinically demonstrated in over 400 studies to be effective for many psychiatric disorders and medical problems for both children and adolescents. It has been recommended in the UK by the National Institute for Health and Clinical Excellence as a treatment of choice for a number of mental health difficulties, including post-traumatic stress disorder, OCD, bulimia nervosa and clinical depression. Cognitive Behavioral Therapy most closely allies with the Scientist-Practitioner Model of Clinical Psychology, in which clinical practice and research is informed by a scientific perspective; clear operationalization of the "problem" or "issue;" an emphasis on measurement (and measurable changes in cognition and behavior); and measurable goal-attainment.


Depression and cognitive behavioral therapy

Negative thinking in depression can result from biological sources (i.e., endogenous depression), modeling from parents, peers or other sources. The depressed person experiences negative thoughts as being beyond their control: the negative thought pattern can become automatic and self-perpetuating.


Negative thinking can be categorized into a number of common patterns called "cognitive distortions." The cognitive therapist provides techniques to give the client a greater degree of control over negative thinking by correcting these distortions or correcting thinking errors that abet the distortions, in a process called cognitive restructuring.


Negative thoughts in depression are generally about one or more of three areas: negative view of self, negative view of the world and negative view of the future. These constitute what Beck called the "cognitive triad." An approach to depression based upon attribution theory in social psychology is related to the concept of attributional style. First put forth by Lyn Abramson and her colleagues in 1978, this approach argues that depressives have a typical attributional style —they tend to attribute negative events in their lives to stable and global characteristics of themselves. There is considerable evidence that depressives do exhibit such an attributional style, but it is important to remember that Abramson et al. do not claim that an attributional style of this nature is necessarily going to cause depression — only that it will lead to clinical depression if combined with a negative event. This theory is sometimes known as a revised version of learned helplessness theory.


In 1989, this theory was challenged by Hopelessness Theory. This theory emphasized attributions to global and stable factors, rather than, as in the original model, internal attributions. Hopelessness Theory also emphasizes that beliefs about the consequences of events and rated importance of events may be at least as important in understanding why some people react to negative events with clinical depression as are causal attributions.


The ABCs of Irrational Beliefs in CBT

A major aid in cognitive therapy is what Albert Ellis called the ABC Technique of Irrational Beliefs. The first three steps analyze the process by which a person has developed irrational beliefs and may be recorded in a three-column table.


* A - Activating Event or objective situation. The first column records the objective situation, that is, an event that ultimately leads to some type of high emotional response or negative dysfunctional thinking.


* B - Beliefs. In the second column, the client writes down the negative thoughts that occurred to them.


* C - Consequence. The third column is for the negative feelings and dysfunctional behaviors that ensued. The negative thoughts of the second column are seen as a connecting bridge between the situation and the distressing feelings. The third column C is next explained by describing emotions or negative thoughts that the client thinks are caused by A. This could be anger, sorrow, anxiety, etc.


For example, Gina is upset because she got a low mark on a math test. The Activating event, A, is that she failed her test. The Belief, B, is that she must have good grades or she is worthless. The Consequence, C, is that Gina feels depressed.



After irrational beliefs have been identified, the therapist will often work with the client in challenging the negative thoughts on the basis of evidence from the client's experience by reframing it, meaning to re-interpret it in a more realistic light. This helps the client to develop more rational beliefs and healthy coping strategies.


From the example above, a therapist would help Gina realize that there is no evidence that she must have good grades to be worthwhile, or that getting bad grades is awful. She desires good grades, and it would be good to have them, but it hardly makes her worthless. If she realizes that getting bad grades is disappointing, but not awful, and that it means she is currently bad at math or at studying, but not as a person, she will feel sad or frustrated, but not depressed. The sadness and frustration are likely healthy negative emotions and may lead her to study harder from then on.


Cognitive Behavioral Therapy with or without drugs for depression

A large-scale study in 2000 showed substantially higher results of response and remission when a form of cognitive behavior therapy and an anti-depressant drug were combined than when either method was used alone.


The American Psychiatric Association Practice Guidelines (April 2000) indicated that among psychotherapeutic approaches, cognitive behavioral therapy and interpersonal therapy had the best-documented efficacy for treatment of major depressive disorder, although they noted that rigorous evaluative studies had not been published.


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Cognitive Behavioral Therapy, or CBT, can be an effective intervention for adults on the autism spectrum who can be prone to depression, anxiety, obsessive-compulsive disorders, bipolar disorders and other mental health issues