Autism and cognitive behavioural therapy (CBT)

Dr Joshua Muggleton is a Clinical Psychologist who received a diagnosis of Asperger syndrome in his mid-teens. Here Joshua discusses how he adapts cognitive behavioural therapy (CBT) when working with people on the autism spectrum.

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Author: Dr Joshua Muggleton

Autism and CBT

“Psychological interventions should be adapted to meet the needs of people on the autism spectrum” – everyone everywhere
Seriously?...Someone was paid for saying that? 
Of course we need to adapt psychological therapies for people on the autism spectrum! I mean, why would we not? For that matter, as therapists, shouldn’t we be adapting our therapies to suit the needs of our clients anyway? 
The reason I think we do have to state the obvious time and again is that, despite everyone realising that we need to adapt therapies for people on the spectrum, people struggle to know how to adapt therapies for people on the spectrum. 
CBT and autism
My introduction to autism adapted psychological therapies was perhaps a bit unusual, as I was a client. As a teenager on the autism spectrum accessing Children and Adolescent Mental Health Services (CAMHS), I took great pleasure in running rings around my therapist and her attempts to challenge what I maintained were perfectly accurate and valid worries and anxieties [newsflash: people on the autism spectrum may make social mistakes and as a result can experience very real feelings of social anxiety!].
I also never really understood how someone was meant to rate their mood on a one to ten scale - tell me, what exactly does an 8 feel like? It was this experience that piqued my interest in studying psychology academically.
Fast forward five years or so, and I landed my first job as an honorary assistant psychologist to a fantastic consultant clinical psychologist who worked exclusively with adults on the autism spectrum. I spent a lot of time observing her sessions and taking notes, and what I saw was often quite different to my “CBT for Dummies” textbook. Although I could clearly see the theory behind CBT driving her work, the application was sometimes very different – all the elements were there, but it was presented in a different language or medium.
Why was it so different? How was she adapting it? Was there guidelines, a textbook, a manual I could read? Not really. 
Naturally, therapists turn to NICE for advice, who in their wisdom make seven suggestions for adapting therapy, including the use of:
  • hobbies and interests
  • simplified cognitive activities 
  • a more ‘cognitively concrete and structured approach’.
These are all great ideas for what to do – making cognitive activities simple is a great idea for anyone! But what they haven’t done is told you how you actually do it. 
When using CBT we try to reveal and challenge negative automatic thoughts, try to shake dysfunctional assumptions and maybe try to be more flexible in our core beliefs. The trouble is (speaking as someone on the spectrum) I’ve never heard of anything so abstract, airy fairy or less concrete in my life! We are starting from a very abstract, generalised model, so it is bound to mean that creating something concrete from it is going to be much harder.
Equally, although CBT can and does explore the usefulness of a person’s thoughts, the manuals often focus on the validity of a person’s thoughts but people on the autism spectrum often have very valid and rational fears/anxieties, as I mentioned above. Not to mention, you are trying to out-logic a group of people who have a very logical mind, who have likely spent a long time thinking about these issues and who often pride ourselves on our intellect…. And you’re trying to tell us we’re wrong? 
Adapted CBT in practice
In 2014 I travelled to Australia to observe Prof Tony Attwood, Dr Michelle Garnett and the staff at the Minds and Hearts clinic in Brisbane to try and pin down what they were doing to make therapy more accessible to people on the autism spectrum.
The result was a 90 page report. In it I blatantly steal try to set out some of the key methods I observed being used, some of which I’ve outlined below. 
The Emotional Toolbox
In essence, the emotional toolbox is a way of getting the clinician to focus on emotional regulation (i.e. coping) strategies the person can use to ‘fix the feeling’, and a way of making the strategies really concrete for the client.
For example if a child likes Minecraft then clinicians can adopt the imagery and terminology used in the game to help explain different emotional regulation strategies. Strategies can take the form of Minecraft tools.  
The Emotional Thermometer
Lots of people have heard of an emotional thermometer – they are a key part of CBT – it’s your basic SUDS – Subjective Units of Distress. However in Australia time was spent on building an individualised thermometer for each emotion, and using this as a way to build emotional literacy.
It will often start with defining times that were ‘happy’, maybe using pictures, stories or videos of the event to help people remember the details of what happened and also how their body felt at the time.  Sometimes we may even use art, music or images on the internet to help the person describe the feelings (words are so clumsy anyway).
We then get the person to rank those events from most to least happy. Sometimes we may need to ask them to be more specific:
  • was A happier than B?
  • was B happier than C? 
  • was C happier than A?
We can then translate these to a 1-10 scale, and roughly attach words to describe these sensations. This gives people a reference point: 
“How I felt when Granny gave me a toy truck is what other people call ‘ecstatic’. It is an 8/10, meaning it is more intense than when my teacher gave me an A, when I was ‘pleased’, because that’s just a 6. When people say they are pleased with me they feel like when I got an A”.
The result of this approach is:
  • you have a common language (your 1-10 rating)
  • you are teaching social skills (understanding what others mean by different emotion words)
  • you are building self-awareness of emotions and how to communicate them.
The same approach can be used to explore negative emotions as well.
The “This is me” book
This is probably the most rewarding thing to do. People on the autism spectrum can have difficulties with some aspects of autobiographical memory (for example, often having a good memory for what others did but finding it harder to remember what they did). This can make it hard for some people to form a positive self-identity as they have difficulties building up positive memories about themselves, particularly given the high rate of bullying people on the spectrum can experience. 
The “This is me” book is a wonderful activity where people gather round and define the persons best qualities and abilities, after which they help the person build a scrap book of drawings, photos, mementos and descriptions of different times they exhibited those qualities and abilities. With time to regularly review and update the book, it can help a person see how much they have to offer and build some much needed self-esteem.
Group work
Groups at Minds and Hearts often followed a similar format – an hour with the child on the spectrum, and then 30 mins with the parents. The child and parents were both given workbooks to follow and fill in, with clear tasks to complete in the week. The structure of the groups also shows how these different tools can be interwoven, and how much time and care should be taken over them.
For example, starting with some self-esteem work using the “This is me” book, then over the next few sessions exploring different emotions, starting with positive ones, so children really have a chance to learn and understand different feelings. Only then are children given the tools in the Emotional Toolbox – after all, if you go around trying to screw in nails with a hammer you’ll give up quickly!
Case study
What the team did wasn’t rocket science. It was really stripped back, practical CBT with a little ‘c’. For example, I mentioned earlier using Minecraft as a way-in to use the emotional toolbox. I had great fun working with a lad who loved the game but who struggled to identify his emotions and was having difficulties at school. The emotional literacy work was important, but he needed strategies to cope with school now if he was to stay in education. 
We linked different Minecraft tools to different situations he found hard. For example, a bully was a creeper (because he made my client want to explode), and so he needed a sword (in this case, telling a teacher and thinking about playing games) to fight it. Whereas Mrs Jones was a Witch (sorry Mrs Jones!) because she was really grouchy, so she needed a bow and arrow (deep breathing). We could then link these tools to physical objects – foam toys of these tools (or photos of them for school). So right now, somewhere in Scotland, there is a lad bouncing on a trampoline holding his Minecraft Axe because his mother told him to come off the computer. 
A toolkit of strategies
This form of CBT went back to basics, with a heavy emphasis on behavioural strategies, coping and psychoeducation, and all delivered to the person and the system around them. Cognition had its place but it was usually done more with adults and kept very simple – thoughts, feelings and behaviours. 
Equally, this approach does not preclude using cognitive therapy – a scientific ‘what evidence do you have for that thought’ approach can work for people on the autism spectrum. However, for me, what I had previously thought of as the whole of CBT became only one part of a much larger toolkit of therapeutic strategies. Equally, of course, this is just one approach and will not be the only way to do things. 
Going to Mind and Hearts and learning how they adapt therapy for people on the spectrum has given me a set of tools to use and inspired me to find new ways to use them. My hope is that other clinicians reading the report will feel equally inspired and empowered as therapists working with people on the spectrum, and find it as rewarding as I have. After all, you know that when someone on the spectrum tells you that you really helped them, we really mean it.
Further reading
Date added: 26 July 2018


Thu, 09/08/2018 - 14:39

I too have found Tony Attwood's Hearts and Minds approach useful but it does not go far enough. Words that describe emotion are culturally defined and situation specific. Establishing a common language for emotion involves sharing the experience. Greater accuracy of meaning can be established if the client feels what the therapist feels. For a greater understanding of others the client needs to accurately assess emotion in others (learning facial expressions does not work! - see Lisa Feldman Barrett). So having an accurate way of labelling emotions is important but also knowing they are separate from their emotions and that emotions exist separately in others is also crucial. This Tony does not do.


Fri, 07/09/2018 - 12:21

"Words that describe emotion are culturally defined and situation specific." How true! As a non-native speaker of English I am well aware of this.  Anger once meant grief/sorrow. The word slowly changed meaning. It may be that there are only basic few feelings but the words descibing them do change meaning, which is a proof that the definition is culturally defined. It doesn't take a genius to figure out that the meaning of all words is culturally defined.

If all that was needed was to learning facial expressions then the problem could be easily solved. My suggestion is to teach definitions of feelings (anxiety is to believe that you are incapable of handling circumstances that may arise) similar to what would be listed in a dictonary. From it you can figure out that if some is worried about being incapable of handling circumstances he/she is anxious. If there are no worries about that the person is not anxious.