For a number of years now, Cognitive Behavioural Therapy (CBT) has been the go-to therapy used by the NHS to help people manage problems by changing the way an individual overcomes difficulties. However, there seems to be contradictory evidence to support the efficacy of CBT for autistic people, leading therapists and clients to question whether or not it works. This article will try and answer one of my most commonly asked questions; does CBT work for autistic people?
Firstly, anything I write, deliver or host that is autism related always starts with a whole-hearted apology to the neuro-diverse community. How can a single article cover the wide range of experiences autistic people encounter? It can’t. I make assumptions, I misunderstand and, at times, the language I use can be viewed as completely wrong.
What I can say is that my thoughts, opinions and actions come from nearly twenty years of experience working with autistic people and their families and by following guidance from organisations like the National Autistic Society. I am still learning, we all are. I just hope if you continue to read, you will assume I have positive intentions and I will try and be as sensitive and respectful as possible. Hopefully, some people will be able to relate, others won’t and I accept this and reassure you all that I will continue to work in collaboration with autistic people and truly value the input and advice I am given.
Why is CBT so popular?
Very briefly, CBT is based on the concept of learning that helps and assists an individual to develop new behaviours as well as change their experience of the environmental reinforcers. It can be more structured and directive than some therapies and usually has a shared agenda between the client and therapist.
It can be described as more active because goal setting and work between sessions is expected and CBT can be considered “time-limited” as a fixed number of sessions are usually offered. Research and empirical evidence measuring the efficacy of CBT suggests an element of success with the majority of clients, hence its popularity, however, there seems to be limited evidence demonstrating the effectiveness of CBT among autistic people.
What is autism?
Autism is described by the National Autistic Society as a complex, life-long developmental disability that typically appears in childhood that can impact a person’s social skills, communication, relationships and self-regulation. In The Diagnostic and Statistical Manual version 5, the diagnostic criteria for Autism Spectrum Disorder (ASD) includes persistent deficits in social communication and interaction, restricted, repetitive patterns of behaviour including hyper and hypoactivity to sensory input, that symptoms must be present in childhood and that symptoms must be clinically significant.
The DSM-5, uses the “medical model” (something I am uncomfortable with) and focuses on the deficits an autistic person faces in their day-to-day life and that these impairments or differences can be “fixed” or changed by medical or other treatments.
When considering the “social model” to diagnose autism, this model underpins the concept of neurodiversity and considers how accommodations can be made in society to reduce barriers, negative attitudes and exclusion. The social model considers individual physical, sensory and/or psychological variations that may cause difficulties (depression and anxiety as examples).
When working with autistic adults, I have found the therapeutic relationship is enhanced when there is a pick and mix of medical and social model aspects to aid my understanding of autism. I recognise not everyone will be happy with this, however, there are some environmental considerations that impact an individual and there are some behaviours, reactions or experiences that also need to be considered.
What makes accessing therapy difficult for autistic people?
It is important to consider the diagnostic criteria (differences not disability) even before working with autistic people. Even before contact is made, it is important to recognise that autistic people will encounter significant levels of anxiety deciding to and accessing therapy.
More often than not, I have found that before therapy even starts, some autistic people may not recognise that therapeutic intervention is needed. They have often described normalising the behaviours/thoughts or found limiting or reducing their routines or interactions reduces anxiety, however, when they have to interact (as an example) there is heightened anxiety. Some clients also believe that change is not needed or that due to rigidity of thought, they have decided change is not possible. It may have been family, friends or other professionals that recommend therapeutic intervention.
Time and time again I always encounter how much of a struggle autistic people have when accessing health care. Examples of communication difficulties create barriers when attempting to make appointments to see health professionals (using telephones or calling at a certain time). If an autistic person finds initial access difficult, this, at the very beginning of the process, causes additional difficulties accessing therapy that non-autistic people never seem to encounter.
If accessing healthcare is possible, clients I have worked with found describing their challenges as another barrier. Repeating their circumstances over and over again becomes exhausting and they are often met with unhelpful stereotyping including “you don’t look autistic, just exercise more, change your diet” as examples. I know that even at an introductory level of autism awareness and acceptance training it should include why such comments are harmful and can prevent accessing therapy.
Sometimes, autistic people tell me they just want to be heard and validated. Autistic people have often said they see themselves as not needing to be “fixed” or changed and the behaviours that are ingrained (accepted) in their day-to-day routines are helpful and should remain. It is, however, how non-autistic people make them feel. It is the anxiety society causes them or why masking their difficulties makes them feel depressed because society can make them feel ashamed of who they really are.
If an autistic person makes the brave decision that therapeutic intervention is needed and they have overcome the barriers to accessing healthcare and have made the choice of who they will engage with, it is important that the therapist engages in a creative and autism-friendly way. Some elements of CBT can offer this flexible approach and with a creative, accepting and knowledgeable therapist, the therapeutic relationship may begin to develop.
How can therapeutic change take place?
CBT is a collaborative relationship between the client and therapist. This should result in both bringing specific elements to the intervention but also the therapist bringing their autism-related experience and knowledge. Often, autistic people think in very black-and-white ways, therefore the relationship can benefit from sharing empirical evidence that supports CBT. Also, it is only the client that truly understands how they experience the world as an autistic person so the therapist, using person-centred core conditions, can build the relationship and consider the most appropriate interventions. CBT is also known to be structured and time-limited. Often, autistic people prefer this framework of the sessions. I always ensure there are clear boundaries and that each session has a “purpose”.
This is in contrast to other modes of therapy, where the client is expected to bring what they need to bring to each session, work through difficulties themselves and direct each session as the expert on themselves. Often, autistic people struggle with knowing what to bring to a session, whereas in CBT, there is already a shared agenda set out from the start.
I have often found that having a set number of sessions also brings reassurance for autistic people. A negative aspect for some autistic people is that the number of sessions can, in some organisations, be unlimited, however, having a clear end helps with clarity and focus. It also reduces the creation of another “routine” whereby attending the sessions could become part of the weekly routine and structure, rather than attending for therapeutic reasons.
I always ensure any CBT techniques I incorporate are clear solution-focused techniques. This means the emphasis is given to the specific experiences that cause the client day-to-day difficulties rather than focusing on the assumed difficulties (assumed by the therapist) associated with a diagnosis. This focus can then lead to achievable goals and strategies that can be tailored to suit the individual.
Often, how to interpret what is discussed and use any changes in behaviour positively can cause additional anxiety. In addition, if an autistic person has no structure, this can cause additional anxiety. Therefore, as the nature of CBT is structured, this approach coupled with the appropriate use of Socratic Questioning to guide the “discovery” of information can often help with changing beliefs and help to make the sessions more autism-friendly by being more “concrete and/or black and white”.
One of the main advantages of CBT is the ability to incorporate feedback, summaries and measurable differences. As long as the autistic client understands how the measurement being used works, having this feedback offers additional reassurance and structure that helps to reduce anxiety. Using scoring techniques can also help with identifying improvements that could help improve self-awareness, and increase self-esteem but also effectively identify when a strategy or technique isn’t working.
Also, one of the main advantages of using CBT with autistic clients is that the therapy isn’t limited to the counselling room. Therapists have the freedom to work in different places, perhaps somewhere quieter, outdoors or where there are fewer sensory stimuli that could cause additional anxiety. In addition, if travelling is a barrier to accessing therapy, CBT isn’t confined to one place but can be used online via Teams or Zoom (as examples).
What CBT techniques work?
I am often asked what CBT techniques work best when working with autistic people. I never answer this as it always depends on the person sitting in front of you (on screen or in person). It is more about building a collection of “therapeutic tools” that suit the client rather than me telling you what to use. That said, I have found techniques including “thoughts are not facts” and “graded exposure” as more autism-friendly, as both can be easily adapted to suit autistic clients. It is because autistic people often think in very black-and-white ways, considering situations that cause heightened anxiety in a way that separates fact from opinion can be easy for autistic people.
Often, thoughts can be extreme, however. When focusing on a specific area, it can be really helpful for an autistic client to separate thoughts to help to reduce catastrophising and increases the ability to make choices and decisions about certain situations with less anxiety. Realising that some thoughts (and reactions) are based on opinions helps to reduce the distress that may be caused.
This approach could be used to help with decision-making, going to new places, starting something new, meeting new people, going shopping, answering the telephone/making telephone calls, opening letters and, among many more examples, travelling on public transport (some of the more common difficulties I have successfully worked on).
By concentrating on one specific cause of anxiety, this approach gives instructions for the autistic person to use and offers a measurable impact of success that can lead to quick improvements leading to improved self-esteem and confidence. Using other therapeutic models in this situation(s) may take weeks to identify difficulties and wouldn’t offer the structure to give the client the practical tools to help overcome the anxiety.
Graded exposure is another tool I use. It offers a step-by-step technique to increase the exposure that can help to reduce the anxiety or panic certain situations can cause. Often, autistic people may be fearful of new situations and tend to avoid them completely. However, clients can be guided to start exposing themselves to build up confidence.
An example could be to just consider being in a new place, then to use Google Maps to look at a new place, then to go with someone for a short period of time and then get the client to travel alone. This approach is autism-friendly and effective as it is relatively easy to break down each step of additional exposure, it increases self-esteem as progress is made, the client decides how quickly to move to each step and this approach is transferable to many different situations.
It is difficult to envisage how other types of therapy would offer any practical solutions in situations similar to this as there would be no clear goals or structure. CBT, on the other hand, is structured and time-limited (with agreement), and the graded exposure steps can be presented visually, resulting in a far more autism-friendly approach.
It would appear that CBT is autism friendly and the techniques used can be adapted to suit autistic clients however, it is vital to include the theoretical underpinnings of Person- Centred Therapy (PCT), as without the three core conditions, empathy, unconditional positive regard and congruence, it is argued that therapeutic change cannot happen.
Discovering the client’s individual perception of themselves and their world is vitally important if therapeutic support is to be effective. Even if two people appear to have the same experience (or diagnosis) they would deal with situations entirely differently and a therapist would need to offer completely different approaches. Additionally, PCT is based on respect for the client, and for the counsellor to be open and genuine with the client (acceptance of autism rather than awareness). Therefore, by using PCT skills, the right conditions for therapeutic change are created.
Finally, a counsellor would also need to understand and remain in a client’s frame of reference or completely understand their unique experience and experiences of being autistic. When a counsellor perceives the client from an external frame of reference (possibly outdated or stereotypical understanding of autism, not understanding the variable nature of autism or how individual and unique autism can be) the counsellor cannot truly begin to appreciate what is actually like for the autistic client and therefore prevent relational depth that leads to therapeutic change. Therefore, before introducing CBT approaches understanding and knowing the client is vital both when working with autistic people and also non-autistic people.
Without hearing the individual’s story or truly getting to know your client, introducing techniques may not be successful as a result. Sometimes, autistic people want to tell their story, be accepted and just be heard rather than be told what to work on, therefore, introducing a combined approach using PCT and CBT, should only be done when appropriate and timely.
So, does CBT work for autistic clients?
Working with autistic people often presents challenges for the counsellor that includes accepting differences in communication, literal interpretation, general misunderstandings (from both client and counsellor), sensory processing differences that need to be considered, that autistic people process verbal information differently and coping with new people and situations can be challenging.
When choosing a therapist, a therapist should have experience working with autistic people but, more importantly, should demonstrate significant levels of acceptance that go far beyond unconditional positive regard. A therapist also needs to consider that autistic brains are wired differently, that skills and strategies often need to be taught explicitly and that when learning new approaches to difficult situations, practice is needed. It is therefore important to consider all the skills and theoretical underpinnings of PCT to ensure a therapist truly knows their client and adapts CBT approaches to suit the individual.
It is also vitally important a therapist introduces CBT strategies to the sessions when the client is ready but in a non-confrontational, creative and autism-friendly way, recognising if the client struggles to practice outside of session times, anxiety or autism-related fatigue may be the cause – not a reluctance to engage.
Finally, the most important thing to consider is to encourage therapists to tailor their interventions to suit the skills and not the deficits of the autistic people they are working with.