CBT for Autism: Teaching the blind to see?;





“How does that make you feel?” “How do you cope with that?” “What is it that makes you anxious?” “Are you Catastrophising?” “Have you tried mentalizing?” “Where do those negative thoughts come from?” “Are you avoiding?” “What is unhelpful about those coping mechanisms?” “Do you remember to breath?” “How about setting goals?”

What-is-CBT_small_whiteAfter several years of dabbling in Cognitive Behavioural Therapy (CBT) one’s brain starts to chuck out these predictable mantras at opportune moments. Going to get on the tube – “what is the anxiety about!?” Worried about the Ebola virus – “is this catastrophising!?” CBT has often been described as a sticking plaster, useful for the worried well but just a scratch on the surface for anyone with deeper or more stubborn difficulties.  The early research seemed to suggest this was the new miracle cure, more effective than Prozac, cheaper than psychotherapy. Everyone was leaving their Drs office cured of their depression and/or anxiety, adding to a growing nation of cognitively intelligent beings. Even hardened Builder’s started identifying their anxiety, learning relaxation techniques. What the health service and those pro CBT failed to tell you, was that the majority of those with actual depression or an anxiety disorder ended up returning to their Drs with recurring complaints; the techniques were wearing off. A revolving door has become a good analogy for these patients. Perhaps this is better than before the CBT era, where patients may have found themselves stuck in long term psychiatric outpatient care, or even in inpatient care, with little ambition of leaving in the near future. Most Psychologists (mostly those not associated with the NHS) do not consider CBT worthy of all this glory however, and studies have been produced showing these flaws and suggesting better therapies and more effective long term solutions. So this week I was surprised to learn that with severe cuts to the mental health service, and with the provision of new care pathways which places patients into neatly labelled boxes, the only therapy being commissioned in the NHS for those with depression or anxiety is CBT. Gone is the art and music therapy, the counsellors and the psychotherapists. Drugs and CBT can cure it all.

For those with little knowledge of what CBT entails and are new to this world, CBT is a ‘psychotherapeutic approach that addresses dysfunctional emotions, maladaptive behaviours and cognitive processes and contents through a number of goal-oriented, explicit systematic procedures’ (thank you Wikipedia). The language used to describe CBT is quite reflective of what the therapy is actually like to experience; cold, robotic and a little confusing. Goals are often set to overcome specific problems, such as a fear or busy places. Your therapist will talk through what makes you feel anxious, what sort of thoughts you are having, how those thoughts affect how you feel and what you do. You will fill in sheet after sheet with these sorts of questions, doing ‘homework’ outside of sessions to achieve an ultimate goal, such as going to a busy shopping centre.

yhst-78359274419338_2271_55889461So sounds like it might be helpful for some people? ‘Some’ being the operative word. For some others it can actually be more damaging, like for some people with autism. How can you give someone the tools to help themselves when they don’t have the mechanisms in place to actually use them? In fact research has found that this group struggles in particular with this sort of therapy, but why?

During my own periods of CBT I found the course too short, too much was expected in such a short period of time. I could not pin point my difficulties to goals, several I could and did achieve, but the deeper ones lay stuck in my autistically developed mind. My therapist would frustratingly and impatiently keep asking me why I felt a certain way, and I could never say. Why do I feel anxious today? I don’t know I just do, well I think I do. One of the impairments of having autism is that there is a sort of block between emotion and cognition. It is why many perceive us to have a lack of empathy, which we categorically do not we just sometimes having difficulty showing it or processing it. So you can see why teaching us ways to think less catastrophically isn’t going to really cut the mustard (odd phrase I will spend the next few minutes working out the literal meaning of).

Stress_and_anxiety_funnyThe problem also lies in the unpredictability of emotions. I generally feel anxious in busy shops, but not always. Sometimes I feel empty in small empty shops. For my homework I could achieve the goal of shopping somewhere busy fine, a week later I might have a panic attack doing it again. Sometimes I might have a panic attack just sat at home watching TV. It is hard to understand where these emotions come from, and sometimes it is easier and best to just accept them as they are. If we cannot understand these things ourselves, how can we communicate them to others? With great difficulty, especially in a talking therapy with a stranger.

The frustration that comes with trying to understand oneself in a ‘neurotypical’ way can be pretty intense. I have admittedly needed further therapy to get over therapy that has exhausted my brain’s processing capacity! If something is going to help anxiety and depression related to autism then it needs to be gentle and compassionate. Two things with the NHS unfortunately cannot provide, making support for adults with autism extremely hard, if not impossible, to find. There is no pathway for individuals with autism spectrum disorders. Those at the high functioning end fall between the gap of learning disability and mental health difficulty, neither quite attending to specific needs. Fortunately there are some great private counsellors around who specialise in these areas, contact your local NAS centre to find out more.

I would like to hear more about your experiences if you have had any with CBT or with NHS mental health services, please leave a comment =]


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7 Comments
  1. I think the operative words, besides “some”, is “specific” and “predictable”. CBT is great for overcoming anxieties with specific, consistent triggers, and specific depressive thoughts, but can’t help with more complex and diffuse mental problems.

    I’ve had great use of CBT-like strategies to overcome my irrational anxiety of talking on the phone, which was a big problem a few years back. It worked – I don’t have that problem anymore, it is almost completely gone and as a result of that I’m much more able in many aspects of my societal life: I can search jobs, use the phone professionally & well in my job, organise things et.c – Phones is a quite essential communication channel which I was prevented from using, and overcoming that anxiety barrier makes a big positive difference for my independence and opportunities (I wrote a blog series about overcoming Telephobia here – quite a CBT success story).

    I have many more other mental problems and even other (occasional) anxiety problems, where CBT is useless, because a bit like you describe with your shopping above: these anxiety issues are diffuse and difficult to define, fluctuate, are periodic, and “hit” randomly rather than linked to specific, predictability triggers. Sensory strategies tend to help better.

  2. Example: I experienced bad panic attacks in May during a flight from Australia to Denmark (a flight of almost 30 hours incl. waits in airports). Flying tends to trigger small panic attacks for me, but not all the time. They seem to happen suddenly out of the blue and not be related to specific thoughts or triggers while flying (typical triggers like turbulence, take-off and landing don’t particularly bother me). I usually manage them by walking around the plane, touching cold surfaces et.c. until the anxiety sinks to a more tolerable level, then I go back to my seat. (Physical/ sensory strategies work best for most of my anxiety issues and other mental issues).

    The flight in May was sudden and in a context of shock & grief: I was flying home for my dad’s funeral. I had very bad panic attacks during most of the flight time and became physically ill too with diarrhoea, head ache, dizziness et.c. I was almost constantly walking around or tried to hold my head down, do my usual sensory-soothing type of things, and also of course tried to manage my stomach pain, nausea and diarrhoea so I had to be close to a toilet. Sitting still immediately made the panic soar out of control, I needed to move constantly or lay down (not an option) – but the plane was crammed, so almost move was impeded by crowding and lack of space. As I walked back and forth in the corridors I walked through changing zones of heat and body smells and perfumes, and some of these also triggered instant sudden soaring of the anxiety sometimes for some reason. My condition escalated so bad the flight crew spent a lot of time trying to help, called a doctor from the plane and asked a doctor amongst the passengers to check me. I got medical oxygen for 1 hour on two of the flights (and it helped), was almost not allowed to get on board the last plane (and my suitcase had been unloaded), was checked by paramedics in the airport and received a lot of help which I’m forever grateful for. Especially the crew on one of the flights were incredible helpful, and I feel like they saved my life.

    Since I had to fly home to Australia again after 3 weeks a repetition of the flight panic was a big worry, and I researched on the Internet things like “flight phobia”… “flight anxiety” “flight and panic attacks” “SPD and flying” “asperger’s and flying” et.c. All I could find was crappy CBT-like tips that assumed specific triggers, such as fear of plane crash. I never worried the plane would fall down, so the tips would be completely besides the point. In the situation, I had little reasoning going on at all during all those hours – it was pure, intense fear flooding my mind and body like unstoppable waves, I could talk and think rationally but not stop the waves. The one thought-like worry I did have, was that I wouldn’t make it to the destination. Given how physically unwell I felt and looked, that didn’t seem irrational in the situation. In any case, it was an outcome of the panic situation rather than the trigger.

  3. I had CBT as part of a research program to try and develop CBT specifically tailored for autistics. As the current model of CBT has several issues for autistics and isn’t really suited at all. In general it followed the same type of model CBT normally does, charts mapping anxiety levels tied to situations, homework etc. However, the focus was more on developping coping strategies in anxious situations, ie. what to do when someone stands to close to you. There was also time spent on learning to recognize ones emotions and to express them when possible. There was also no focus on removing anxiety alltogether, as in some cases that is just not possible, but rather to decrease it as much as you can. We worked with diagrams, pictures etc. and I got copies of what we worked on as well, and I also got to do a lot of my own drawing, not pretty but well, what shall one do.

    In short it is a therapy that is meant to give coping strategies the autistic way. Recognizing the differences in which we process the world and learning to work with them rather than against. It’s a tad hard to explain I find, as therapy things often are for me, so I apologise for the waffling. I didn’t have many sessions (I think it was 12) and then my time in the project was finnished, if I had the money I’d consider seeing the therapist privatley since she is by far the most skilled I’ve met so far in helping me understand myself and teaching me tools so I can manage the things I find difficult. I’m nowhere near there, at the end (and one never really is I find) but I’m one step closer because of her.

    I should also add that my experiences with regular CBT was not successfull, at all.

  4. Pingback: My Age of Autism Anxiety | Aspertypical

  5. I had a very bad experience after being pressured by well meaning doctors into having CBT. I reluctantly went along to the session with a little hope in my heart that this might be the thing that actually helps me. I couldn’t have been more wrong, with the “therapist” asking me over and over again what it is about people that makes me anxious, a question that I couldn’t answer then and a question that I still can’t answer now. This “therapy” session was the start of a very bad time for me when I became completely unable to leave the house for about 6 months. I am currently seeking a diagnosis for Aspergers as my current, very kind and patient therapist (not CBT) has advised me to do. Reading your blog a lot of what you are saying sounds very relevant to me and helps me get over the slightly skepical response I got from my GP when I asked to be referred to a specialist.

  6. I had a very bad experience after being pressured by well meaning doctors into having CBT. I reluctantly went along to the session with a little hope in my heart that this might be the thing that actually helps me. I couldn’t have been more wrong, with the “therapist” asking me over and over again what it is about people that makes me anxious, a question that I couldn’t answer then and a question that I still can’t answer now. This “therapy” session was the start of a very bad time for me when I became completely unable to leave the house for about 6 months. I am currently seeking a diagnosis for Aspergers as my current, very kind and patient therapist (not CBT) has advised me to do. Reading your blog a lot of what you are saying sounds very relevant to me and helps me get over the slightly skepical response I got from my GP when I asked to be referred to a specialist.

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