Cognitive-Behavior Therapy for Adults with Asperger's Syndrome ...

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Cognitive-Behavior Therapy for Adults with Asperger's Syndrome ...

  1. 1. Cognitive-Behavior TherapyCognitive-Behavior Therapy for Adults with Asperger'sfor Adults with Asperger's Syndrome and High-Syndrome and High- Functioning AutismFunctioning Autism Valerie Gaus, Ph.D. gaus@optonline.net 631-692-9750
  2. 2. QUESTIONS TO BE ADDRESSEDQUESTIONS TO BE ADDRESSED TODAYTODAY  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. 3. DISADVANTAGES FACED BYDISADVANTAGES FACED BY ADULTS WITH ASDADULTS 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. 4. COMMON TRIGGERS FORCOMMON TRIGGERS FOR REFERRAL TO MENTAL HEALTHREFERRAL TO MENTAL HEALTH TREATMENTTREATMENT  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. 5. PRESENTING PROBLEMS FORPRESENTING PROBLEMS FOR PSYCHOTHERAPYPSYCHOTHERAPY  anxiety  depression  loneliness  “social skill deficits”  problems with employment/school  problems with dating  poor judgment  poor problem-solving ability
  6. 6. ASPERGER SYNDROME ASASPERGER SYNDROME AS A SOCIAL-COGNITIVEA SOCIAL-COGNITIVE DISABILITYDISABILITY
  7. 7. SOCIAL FEATURESSOCIAL 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. 8. COGNITIVE FEATURESCOGNITIVE 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. 9. ASPERGER SYNDROME AS AASPERGER SYNDROME AS A SOCIAL-COGNITIVE DISABILITYSOCIAL-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. 10. COGNITIVECOGNITIVE FUNCTIONFUNCTION 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. 11. COGNITIVE DYSFUNCTONCOGNITIVE 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. 12. COGNITIVE DEFICITSCOGNITIVE DEFICITS  INPUT – Problems with sensory perception – Inability to filter out irrelevant stimuli – Problems attending to relevant stimuli
  13. 13. COGNITIVE DEFICITSCOGNITIVE 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. 14. COGNITIVE DEFICITSCOGNITIVE DEFICITS  OUTPUT – Inability or poor use of language – Poor motor skills – Problems withholding output until processing is complete (impulsivity)
  15. 15. COGNITIVE DISTORTIONSCOGNITIVE DISTORTIONS  Distorting the MAGNITUDE of a situation – Catastrophizing – Overgeneralizing – Dichotomous thinking (“black and white” or “all or nothing” thinking)
  16. 16. COGNITIVE DISTORTIONSCOGNITIVE 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. 17. COGNITIVE DISTORTIONSCOGNITIVE DISTORTIONS  Holding unrealistic EXPECTATIONS for a given situation – Expecting self to be perfect – Pessimism: expecting things to always go wrong
  18. 18. COGNITIVE DYSFUNCTIONCOGNITIVE DYSFUNCTION IN ASPERGER SYNDROMEIN ASPERGER SYNDROME
  19. 19. COGNITIVE DYSFUNCTION IN AS:COGNITIVE DYSFUNCTION IN AS: Maladaptive Processing of ThreeMaladaptive Processing of Three Types of InformationTypes of Information Information about others Information about self Non-social information
  20. 20. Dysfunctional Processing ofDysfunctional Processing of Information about OTHERS:Information about OTHERS: “Social Cognition”“Social Cognition”
  21. 21. SOCIAL COGNITIONSOCIAL COGNITION General DefinitionGeneral 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. 22. INPUT AND OUTPUT IN A SOCIALINPUT AND OUTPUT IN A SOCIAL SITUATIONSITUATION From Gottman, Notarius, Gonso & Markman (1976)From Gottman, Notarius, Gonso & Markman (1976)
  23. 23. SOCIAL COGNITIONSOCIAL 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. 24. HowHow do people make such inferences? They mustdo people make such inferences? They must be able tobe able to extract meaningextract meaning from: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. 25. Dysfunctional Processing ofDysfunctional Processing of Information about OTHERSInformation 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. 26. Dysfunctional Processing ofDysfunctional Processing of Information about SELFInformation 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. 27. Dysfunctional Processing ofDysfunctional Processing of Information about NON-SOCIALInformation about NON-SOCIAL EnvironmentEnvironment  Executive Functions (Ozonoff, South & Provencal, 2005) • Planning & goal-setting • Organizing • Shifting sets and/or flexibility  Central Coherence (Happé, 2005)
  28. 28. Interrelationship Between CoreInterrelationship Between Core Deficits in Information ProcessingDeficits in Information Processing Non-social Information Information About Others Information About Self Core Information Processing Disorder
  29. 29. SOCIAL-COGNITIVE DISABILITYSOCIAL-COGNITIVE DISABILITY AS A RISK FACTOR FOR CO-AS A RISK FACTOR FOR CO- MORBID MENTAL HEALTHMORBID MENTAL HEALTH PROBLEMSPROBLEMS Poor Social Support Chronic Stress
  30. 30. ANXIETY DEPRESSION 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. 31. HOW CAN A THERAPIST HELPHOW CAN A THERAPIST HELP ANYANY PERSON STRUGGLING WITHPERSON STRUGGLING WITH ANXIETY OR DEPRESSION?ANXIETY OR DEPRESSION?
  32. 32. RATIONALE FOR USE OFRATIONALE FOR USE OF COGNITIVE-BEHAVIOR THERAPYCOGNITIVE-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. 33. CBT HistoryCBT 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. 34. BASIC ASSUMPTIONS OF COGNITIVEBASIC ASSUMPTIONS OF COGNITIVE BEHAVIORAL THERAPY (CBT)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. 35. How is CBT similar to traditionalHow is CBT similar to traditional behavior therapy?behavior therapy?  Both assume problems can be addressed by teaching people ways to change behavior  Both assess outcome in measurable terms
  36. 36. How is CBT different thanHow is CBT different than traditional behavior therapy?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. 37. Environmental Event Behavioral Response Behavioral Response Environmental Event Cognitive Activity
  38. 38. RATIONALE FOR USE OFRATIONALE FOR USE OF COGNITIVE-BEHAVIOR THERAPYCOGNITIVE-BEHAVIOR THERAPY FOR ASPERGER SYNDROMEFOR ASPERGER SYNDROME Presenting problems in people with Asperger Syndrome are often maintained by cognitive and social factors.
  39. 39. WHY HAS CBT NOT BEENWHY HAS CBT NOT BEEN APPLIED TO THEAPPLIED TO THE POPULATIONPOPULATION MOST AT RISK FORMOST AT RISK FOR COGNITIVE PROBLEMS?COGNITIVE PROBLEMS?
  40. 40. ASSESSMENTASSESSMENT
  41. 41. ASSESSMENTASSESSMENT  Explore multiple factors (Gardner & Sovner, 1994). Is the presenting problem being maintained by…. medical factors? psychiatric factors? environmental factors? social factors? cognitive factors?
  42. 42. ASSESSMENT OFASSESSMENT OF COGNITIVE FACTORSCOGNITIVE FACTORS  What cognitiveWhat cognitive deficitsdeficits are maintaining myare maintaining my client’s problem? Therefore, what skillsclient’s problem? Therefore, what skills might I teach my client?might I teach my client?  What cognitiveWhat cognitive distortionsdistortions are maintainingare maintaining my client’s problem? Therefore, whatmy client’s problem? Therefore, what maladaptive thoughts and beliefs can bemaladaptive thoughts and beliefs can be targeted and replaced to alleviatetargeted and replaced to alleviate distress?distress?
  43. 43. COGNITIVE MODELCOGNITIVE MODEL (From(From Cognitive Therapy: Basics and BeyondCognitive Therapy: Basics and Beyond, Judith S. Beck, 1995), Judith S. Beck, 1995) CORE BELIEF INTERMEDIATE BELIEF Situation -> AUTOMATIC THOUGHT -> Emotion
  44. 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. 45. ASSESSMENTASSESSMENT  Use of questions to elicit maladaptive beliefs Socratic questioning Downward arrow techniques
  46. 46. COGNITIVE RESTRUCTURINGCOGNITIVE 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. 47. ABC ModelABC Model (Based on Ellis)(Based on Ellis) AA AACCTTIIVVAATTIINNGG EEVVEENNTT BB BBEELLIIEEFF ((IIRRRRAATTIIOONNAALL)) CC CCOONNSSEEQQUUEENNCCEE ((EEMMOOTTIIOONNAALL)) 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 Fear, anxiety My sister criticized me today. I must be accepted and praised by everyone all of the time, or I am a bad person. Guilt, shame
  48. 48. ABC Model: Restructuring “B”ABC Model: Restructuring “B” A ACTIVATING EVENT BB BBEELLIIEEFF ((RRAATTIIOONNAALL SSUUBBSSTTIITTUUTTEE)) C 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. Momentary mild anxiety My sister criticized me today. Sometimes I do things 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. Mild disappointment
  49. 49. COGNITIVE RESTRUCTURINGCOGNITIVE RESTRUCTURING METHODS FOR PEOPLE WITH ASDMETHODS FOR PEOPLE WITH ASD  The Thought Chain  Social Stories (Carol Gray, 1995)  Comic Strip Conversations (Carol Gray, 1994)
  50. 50. THE THOUGHT CHAIN Gaus, 2000
  51. 51. My roommate asked me to clean up crumbs from the counter top. I will be homeless, soon!
  52. 52. My roommate asked me to clean up crumbs from the counter top. Soon I will be homeless.
  53. 53. 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.
  54. 54. SOCIAL STORIES
  55. 55. My name is Julie. I see Dr. Gaus in therapy every week. Today I am going to see her in a new place
  56. 56. 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
  57. 57. 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.”
  58. 58. 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.
  59. 59. People feel offended when they are asked to give away their “private food”. Sometimes when people feel offended, they hide those feelings.
  60. 60. 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.
  61. 61. COMIC STRIP CONVERSATIONS
  62. 62. Spoken words - things we say out loud. Thoughts - things we say silently to ourselves.
  63. 63. Comic Strip ConversationsComic Strip Conversations Symbol for “Listen”Symbol for “Listen”
  64. 64. Comic Strip ConversationsComic Strip Conversations “What would you like him to hear?”“What would you like him to hear?”
  65. 65. Comic Strip ConversationsComic Strip Conversations “What would you like to hear from him?”“What would you like to hear from him?”
  66. 66. ASSERTIVENESS SKILLSASSERTIVENESS SKILLS TRAININGTRAINING  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)
  67. 67. ASSERTIVENESS SKILLSASSERTIVENESS SKILLS TRAININGTRAINING  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
  68. 68. ASSERTIVENESS SKILLSASSERTIVENESS SKILLS TRAININGTRAINING  Talk Blocks (Innovative Interactions, 2000)* I FEEL frustrated I NEED to be listened to * www.talkblocks.com
  69. 69. ASSERTIVENESS SKILLSASSERTIVENESS SKILLS TRAININGTRAINING  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)
  70. 70. ASSERTIVENESS SKILLSASSERTIVENESS SKILLS TRAININGTRAINING 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.
  71. 71. GUIDELINES FOR USING CBT FORGUIDELINES FOR USING CBT FOR PEOPLE WITH Asperger SyndromePEOPLE 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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