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Cognitive-Behavior Therapy for Adults with Asperger's Syndrome and High-Functioning Autism. Valerie Gaus, Ph.D. [email protected] 631-692-9750. QUESTIONS TO BE ADDRESSED TODAY. What are the unique challenges faced by adults with Asperger’s Disorder and their families? - PowerPoint PPT Presentation
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Cognitive-Behavior Therapy Cognitive-Behavior Therapy for Adults with Asperger's for Adults with Asperger's
Syndrome and High-Syndrome and High-Functioning AutismFunctioning Autism
Valerie Gaus, Ph.D.
631-692-9750
QUESTIONS TO BE ADDRESSED QUESTIONS 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?
DISADVANTAGES FACED BY DISADVANTAGES 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
COMMON TRIGGERS FOR COMMON TRIGGERS FOR REFERRAL TO MENTAL HEALTH REFERRAL 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
PRESENTING PROBLEMS FOR PRESENTING PROBLEMS FOR PSYCHOTHERAPYPSYCHOTHERAPY
anxiety depression loneliness “social skill deficits” problems with employment/school problems with dating poor judgment poor problem-solving ability
ASPERGER SYNDROME AS ASPERGER SYNDROME AS A SOCIAL-COGNITIVE A SOCIAL-COGNITIVE
DISABILITYDISABILITY
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
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
ASPERGER SYNDROME AS A ASPERGER 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
COGNITIVECOGNITIVE FUNCTION FUNCTION
INPUT
Brain receives input from sense
organs andfilters out
irrelevant data;also called
“perception”
PROCESSING
Brain sorts,organizes, stores,
compares,categorizes,
foresees, plans,formulatesusing the incoming
information
OUTPUT
Brain controlsand producesoutput as a
verbal statementor other behaviorthat is hopefully
an adaptiveresponse tothe original
input
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
COGNITIVE DEFICITSCOGNITIVE DEFICITS
INPUT
– Problems with sensory perception– Inability to filter out irrelevant stimuli– Problems attending to relevant stimuli
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”
COGNITIVE DEFICITSCOGNITIVE DEFICITS
OUTPUT
– Inability or poor use of language– Poor motor skills– Problems withholding output until processing
is complete (impulsivity)
COGNITIVE DISTORTIONSCOGNITIVE DISTORTIONS
Distorting the MAGNITUDE of a situation
– Catastrophizing– Overgeneralizing – Dichotomous thinking (“black and white” or
“all or nothing” thinking)
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
COGNITIVE DISTORTIONSCOGNITIVE DISTORTIONS
Holding unrealistic EXPECTATIONS for a given situation
– Expecting self to be perfect – Pessimism: expecting things to always go
wrong
COGNITIVE DYSFUNCTION COGNITIVE DYSFUNCTION IN ASPERGER SYNDROMEIN ASPERGER SYNDROME
COGNITIVE DYSFUNCTION IN AS:COGNITIVE DYSFUNCTION IN AS:Maladaptive Processing of Three Maladaptive Processing of Three
Types of InformationTypes of Information
Information about others
Information about self
Non-social information
Dysfunctional Processing of Dysfunctional Processing of Information about OTHERS: Information about OTHERS:
“Social Cognition”“Social Cognition”
SOCIAL COGNITIONSOCIAL COGNITIONGeneral 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)
INPUT AND OUTPUT IN A SOCIAL INPUT AND OUTPUT IN A SOCIAL SITUATIONSITUATION
From Gottman, Notarius, Gonso & Markman (1976)From Gottman, Notarius, Gonso & Markman (1976)
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.
HowHow do people make such inferences? They must do people make such inferences? They must be able to be 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
Dysfunctional Processing of Dysfunctional 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)
Dysfunctional Processing of Dysfunctional 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)
Dysfunctional Processing of Dysfunctional Processing of Information about NON-SOCIAL Information about NON-SOCIAL
EnvironmentEnvironment
Executive Functions (Ozonoff, South & Provencal, 2005)
• Planning & goal-setting • Organizing • Shifting sets and/or flexibility
Central Coherence (Happé, 2005)
Interrelationship Between Core Interrelationship Between Core Deficits in Information ProcessingDeficits in Information Processing
Non-social Information
InformationAboutOthers
Information About Self
Core
InformationProcessing
Disorder
SOCIAL-COGNITIVE DISABILITY SOCIAL-COGNITIVE DISABILITY AS A RISK FACTOR FOR CO-AS A RISK FACTOR FOR CO-
MORBID MENTAL HEALTH MORBID MENTAL HEALTH PROBLEMSPROBLEMS
Poor Social Support
Chronic Stress
ANXIETYDEPRESSION
CORE PROBLEM PROCESSINGINFORMATION
ABOUT OTHERS
CORE PROBLEM PROCESSINGINFORMATIONABOUT SELF
CORE PROBLEM PROCESSINGNON-SOCIAL INFORMATION
BEHAVIORAL DIFFERENCES
“Social Skill Deficits”
SELFMANAGEMENT
Deficits in Activities of Daily Living
SOCIAL CONSEQUENCES
DAILY LIVING CONSEQUENCES
Poor Social
Support
Chronic Stress
HOW CAN A THERAPIST HELP HOW CAN A THERAPIST HELP ANYANY PERSON STRUGGLING WITH PERSON STRUGGLING WITH
ANXIETY OR DEPRESSION?ANXIETY OR DEPRESSION?
RATIONALE FOR USE OF RATIONALE 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)
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
BASIC ASSUMPTIONS OF COGNITIVE BASIC 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.
How is CBT similar to traditional How 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
How is CBT different than How 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
EnvironmentalEvent
BehavioralResponse
BehavioralResponse
EnvironmentalEvent Cognitive
Activity
RATIONALE FOR USE OF RATIONALE FOR USE OF COGNITIVE-BEHAVIOR THERAPY COGNITIVE-BEHAVIOR THERAPY
FOR ASPERGER SYNDROMEFOR ASPERGER SYNDROME
Presenting problems in people with Asperger Syndrome are often maintained by cognitive and social factors.
WHY HAS CBT NOT BEEN WHY HAS CBT NOT BEEN APPLIED TO THE APPLIED TO THE POPULATIONPOPULATIONMOST AT RISK FORMOST AT RISK FORCOGNITIVE PROBLEMS?COGNITIVE PROBLEMS?
ASSESSMENTASSESSMENT
ASSESSMENTASSESSMENT 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 ASSESSMENT OF COGNITIVE FACTORSCOGNITIVE FACTORS
What cognitive What cognitive deficitsdeficits are maintaining my are maintaining my client’s problem? Therefore, what skills client’s problem? Therefore, what skills might I teach my client?might I teach my client?
What cognitive What cognitive distortionsdistortions are maintaining are maintaining my client’s problem? Therefore, what my client’s problem? Therefore, what maladaptive thoughts and beliefs can be maladaptive thoughts and beliefs can be targeted and replaced to alleviate distress?targeted and replaced to alleviate distress?
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
CORE BELIEFI am stupid.
INTERMEDIATE BELIEFIf I don’t understand something the first time I try, it shows
I can’t learn.
Situation -> AUTOMATIC THOUGHT -> EmotionNew job -> I will never learn all of this -> Anxiety
ASSESSMENTASSESSMENT Use of questions to elicit maladaptive
beliefs
Socratic questioning
Downward arrow techniques
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
ABC ModelABC Model(Based on Ellis)(Based on Ellis)
AAAACCTTIIVVAATTIINNGG EEVVEENNTT
BBBBEELLIIEEFF ((IIRRRRAATTIIOONNAALL))
CCCCOONNSSEEQQUUEENNCCEE
((EEMMOOTTIIOONNAALL))
Someone saidsomething at work thatreminded me of when Iwas beat up in school.
I was helpless then so Iwill always be helpless.I cannot cope withanything
Fear, anxiety
My sister criticized metoday.
I must be accepted andpraised by everyone allof the time, or I am a badperson.
Guilt, shame
ABC Model: Restructuring “B”ABC Model: Restructuring “B”
AACTIVATING EVENT
BBBBEELLIIEEFF ((RRAATTIIOONNAALL
SSUUBBSSTTIITTUUTTEE))
CCONSEQUENCE
(EMOTIONAL)
Someone saidsomething at work thatreminded me of when Iwas beat up in school.
I felt helpless then but Iam helping myself now.I can continue to helpmyself in many ways.
Momentary mild anxiety
My sister criticized metoday.
Sometimes I do thingswell and sometimes not.I am not perfect. Nobodyis. I can do the best Ican and my sister maynot always see that.
Mild disappointment
COGNITIVE RESTRUCTURING COGNITIVE RESTRUCTURING METHODS FOR PEOPLE WITH ASDMETHODS FOR PEOPLE WITH ASD
The Thought Chain
Social Stories (Carol Gray, 1995)
Comic Strip Conversations (Carol Gray, 1994)
THE THOUGHT CHAINGaus, 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 livingindependently.
They will probably throw me out within
the week.
I deserve to bethrown out of my
apartment.
Everyone would be better off without me.
I am not worthy oftaking money from
the taxpayers.
Disabled people area drain on the taxpayers.
I am just anotherdisabled person,
a nut.
I am not capable anddo not deserve the
chance to liveindependently.
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
Spoken words - thingswe say out loud.
Thoughts - thingswe say silently to
ourselves.
Comic Strip Conversations Comic Strip Conversations Symbol for “Listen”Symbol for “Listen”
Comic Strip Conversations Comic Strip Conversations “What would you like him to hear?”“What would you like him to hear?”
Comic Strip Conversations Comic Strip Conversations “What would you like to hear from him?”“What would you like to hear from him?”
ASSERTIVENESS SKILLS ASSERTIVENESS 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)
ASSERTIVENESS SKILLS ASSERTIVENESS 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
* www.talkblocks.com
ASSERTIVENESS SKILLS ASSERTIVENESS SKILLS TRAININGTRAINING
Talk Blocks (Innovative Interactions, 2000)*
I FEEL frustrated
I NEED to be listened to
* www.talkblocks.com
ASSERTIVENESS SKILLS ASSERTIVENESS 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)
ASSERTIVENESS SKILLS ASSERTIVENESS 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.
GUIDELINES FOR USING CBT FOR GUIDELINES 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.