Cognitive Behaviour Therapy for People with Asperger Syndrome

Abstract

People with Asperger syndrome (AS) appear to have higher than expected rates of co-morbid psychiatric disorder. The main co-morbid diagnoses are anxiety disorders and depression, but eating disorders, obsessive compulsive disorder, substance abuse and bipolar affective disorder have all been reported. Cognitive Behaviour Therapy (CBT) is used effectively to treat these conditions, so could it be used in people who also have Asperger syndrome? This paper reviews important components and characteristics of cognitive behaviour therapy in relation to its use with people who have Asperger syndrome with reference to the relevant literature and to feedback from people with AS. The use of CBT in people with Asperger syndrome appears promising, but further work is needed to evaluate its effectiveness and to examine which particular aspects of therapy are helpful.

Full text

Behavioural and Cognitive Psychotherapy, 2006, 34, 293–303
Printed in the United Kingdom doi:10.1017/S1352465805002651
Cognitive Behaviour Therapy for People with
Asperger Syndrome
Stephen Anderson and Jane Morris
Lothian Primary Care, Edinburgh, UK
Abstract. People with Asperger syndrome (AS) appear to have higher than expected rates
of co-morbid psychiatric disorder. The main co-morbid diagnoses are anxiety disorders
and depression, but eating disorders, obsessive compulsive disorder, substance abuse and
bipolar affective disorder have all been reported. Cognitive Behaviour Therapy (CBT) is
used effectively to treat these conditions, so could it be used in people who also have Asperger
syndrome? This paper reviews important components and characteristics of cognitive behaviour
therapy in relation to its use with people who have Asperger syndrome with reference to the
relevant literature and to feedback from people with AS. The use of CBT in people with
Asperger syndrome appears promising, but further work is needed to evaluate its effectiveness
and to examine which particular aspects of therapy are helpful.
Keywords: Asperger syndrome, cognitive behaviour therapy.
Introduction
In 1944 Hans Asperger, described “autistic psychopathy” (Asperger, 1944), but the paper was
published in the German literature, and his work was not brought to light in the international
community until 1981 when Lorna Wing introduced the term “Asperger’s syndrome” (Wing,
1981). The syndrome is regarded as an autism spectrum disorder, with impairments in the triad
of communication, social interaction and imagination (Gillberg and Gillberg, 1989).
There is growing evidence that people with Asperger syndrome (AS) have higher than
expected rates of comorbid psychiatric disorder and there is an increased rate of affective
disorders in families of those with AS (Bolton, Pickles, Murphy and Rutter, 1998). A study
of children with AS showed that one-fifth of the sample had “clinically relevant” levels
of depression, and the group had substantially higher levels of anxiety than children of a
similar age (Kim, Szatmari, Bryson, Streiner and Wilson, 2000). In adolescents and adults,
depression is the most common secondary diagnosis, but obsessive compulsive disorder
(OCD), alcohol and drug abuse, eating disorders, bipolar affective disorder, schizophrenia
and isolated psychotic episodes, catatonia and suicidal thoughts and acts have been reported
(Tantam, 1988a, b; Tantam, 1991; Ghaziuddin, Weidmer-Mikhail and Ghaziuddin. 1998;
Nilsson, Gillberg, Gillberg and R˚
astam, 1999; Tonge, Brereton, Gray and Einfeld, 1999;
Reprint requests to Stephen Anderson, Specialist Registrar in the Psychiatry of Learning Disabilities, Learning
Disabilities Service, Lothian Primary Care, 65 Morningside Drive, Edinburgh EH10 5NQ, UK. E-mail:
stephen.anderson@lpct.scot.nhs.uk
© 2006 British Association for Behavioural and Cognitive Psychotherapies

294 S. Anderson and J. Morris
Gillberg and Billstedt, 2000; Hare and Malone, 2004; Clarke, Littlejohns, Corbett and Joseph,
1989).
Cognitive Behaviour Therapy (CBT), a brief, structured form of psychotherapy originally
developed for the treatment of depression (Beck, Rush, Shaw and Emery, 1979), is problem-
oriented, focusing on the psychological and situational problems that contribute to the client’s
distress, and developing more effective coping skills. CBT has been adapted for use in a range
of disorders, including anxiety disorders, eating disorders, addictions and psychosis, with
specific, evidence-based models of therapy for each condition (e.g. Hawton, Salkovkis, Kirk
and Clark, 1989; Blackburn and Davidson, 1990; Beck, Wright, Newman and Liese, 1993;
Wells, 1997). The classic model has been most drastically and creatively modified for use in
psychosis (Tarrier et al., 1998), complex eating disorders (Fairburn, Marcus and Wilson, 1993)
and OCD (Salkovskis, 1999).
Given that CBT is used effectively to treat the mental health problems that appear to be
over-represented in Asperger syndrome, would it be effective in treating these disorders in
people who have the additional problems imposed by AS, and how might it need to be
modified? Wing (1981) suggested the possibility of using the “innate logicality of the person
with Asperger’s syndrome to effect therapeutic change”. Two case studies detailing the use
of CBT in depressed adults with AS were published in 1997 (Hare, 1997; Hare and Paine,
1997). It was hoped that this would lead to more detailed investigation of the use of CBT in
people with AS. To date, a further single case study of a child with OCD and AS (Reaven
and Hepburn, 2003), an evaluation of a group CBT program for anxiety in children with
AS (Sofronoff and Attwood, 2003) and a case report on the treatment of social anxiety
disorder in an adult with AS (Cardaciotto and Herbert, 2004) are the only studies that appear
in the literature in this area. In addition to these studies, Attwood has published further
discussion of modifications to CBT for use in children and adolescents with AS (Attwood,
2003a, b).
Most of the literature on Autism Spectrum Disorders focuses on children and adolescents.
However, these disorders lead to lifelong disabilities and services are gradually developing
for adults with AS. This paper discusses important components and characteristics of CBT
in relation to its use with people who have Asperger syndrome with reference to the relevant
literature and to feedback from people of all ages who have AS.
Collaborative therapeutic relationship
The therapeutic relationship is a vital component of any form of successful psychotherapy.
In CBT, the term “collaborative” is used to denote the fact that client and therapist work
together to formulate and resolve the client’s problems. Asperger syndrome is defined by
serious difficulties in reciprocal social interaction, evident in both verbal and non-verbal
communication. Difficulties forming and maintaining relationships may be particularly evident
in the one-to-one therapeutic relationship in which we are attempting not only to establish a new
relationship, but asking the person to discuss their thoughts and feelings. Psychotherapeutic
relationships are often highly emotionally charged, and in CBT, moments of heightened
emotion are often used as signals to look for automatic thoughts, assumptions and beliefs that
mediate emotional distress.
AS may go undiagnosed until the person presents for help with depression, anxiety or
social difficulties. The person may have already received inappropriate psychopharmacological

CBT and Asperger Syndrome 295
treatment without AS being recognized (Ryan, 1992). If AS is recognized, what can be done
to improve the therapeutic relationship and make it more bearable for the client?
Hare and Flood (2000) suggest that it “may be more useful not to make an empathic
therapeutic relationship the basis of clinical work with a person with a diagnosis of Asperger’s
syndrome. Instead, explicit agreements on the joint purpose of the sessions may be more
appropriate, given that the problems in empathic intersubjectivity may be central to the
person’s social difficulties”. These authors also suggest that a one-off “download” of personal
information during sessions may have benefits over a more traditional reciprocal interview in
which each party takes turns communicating. A more directive approach may be necessary at
times rather than a truly collaborative therapeutic relationship.
The person with AS may have idiosyncratic ways of expressing thoughts and emotions,
including having specific names for symptoms and experiences. The therapist should discover
and use these idiosyncratic terms. For one 7-year-old girl, it was important for the therapist
to use the child’s term “urges and phases” to describe her intrusive obsessive thoughts and
engage her in therapy (Reaven and Hepburn, 2003). Renaming symptoms in the patient’s
own terms is a common technique in CBT for children and adolescents, but may be equally
important in working with adults with AS who often interpret language in a very literal
way.
The use of visual materials such as diaries and diagrams, writing in addition to verbal
communication during sessions, the use of tape recording, and working together on a computer
are other possibilities for “distancing” the individual from the uncomfortable personal
interaction, whilst still obtaining information regarding situations, thoughts and emotions
to be worked on in CBT. Computerized CBT is showing promise in terms of efficacy and
cost-effectiveness in primary care (Proudfoot et al., 2004, McCrone et al., 2004), and may be
useful for people with AS, although this has not been evaluated.
The problem with depression is that you want to cut yourself off from others, you just cannot face
being “probed” even more than is usually the case with AS people. One on one is really hard. I can
talk to you like this because I am on a computer but if I met you face to face it would be hopeless. I
would be unable to communicate very well at all. Most of the AS people I know can communicate
best in writing like this. CBT by computer would be helpful.
These (and subsequent) comments were received in response to a request posted on an AS
internet forum for feedback from anyone with AS who had used CBT.
Assessment and formulation
Beck’s cognitive model hypothesizes that emotions and behaviours are influenced by one’s
perception of events (Beck et al., 1979). Different people have very different perceptions of
the same event because information and experiences are assessed against a set of fairly rigidly
held beliefs, rules or assumptions about the world, the self and other people. These “schemas”
are developed from early life experience, and may be considered dysfunctional if held too
rigidly or extremely.
Filtering situations and events through dysfunctional assumptions leads to a stream
of negative automatic thoughts associated with emotional change (anxiety, depression),
behavioural change (withdrawal, reduced activity) and physical change (loss of appetite,
sleep disturbance). Characteristic patterns of thinking occur in depression (negative view of

296 S. Anderson and J. Morris
the self, the world and the future) and anxiety disorders (the self is vulnerable, the world
is threatening, and the future is unpredictable and dangerous). Early experience in AS may
include a sense of being different and not fitting in, being teased and bullied, and having
problems making friends. Such experiences are likely to increase in adolescence and early
adulthood, and the world may be seen as frightening and unpredictable, other people as cruel
and uncaring, and the self as vulnerable. Personal accounts of AS give valuable insights into
these immense difficulties and ways of dealing with them (Jackson, 2002; Holliday Willey,
2003). Collaborative development of a visually-based diagrammatic formulation of difficulties,
their development and maintaining factors may be even more helpful in people with AS, given
their preference for more concrete presentations.
CBT assessment generally includes the completion of baseline symptom rating scales,
such as the Beck Depression Inventory. Repeated ratings are then used to monitor progress.
There are, however, no studies validating the use of general instruments in populations with
AS. Informant information, behaviourally anchored measures (weight, sleep patterns, activity
monitoring) and visual measures of subjective distress, such as the “emotional thermometer”
(discussed later) can be used for baseline information and monitoring. Visually based systems
for monitoring thoughts and feelings have been developed and evaluated for CBT with learning
disabled adults and may be equally useful for those with AS (Lindsay, Howells and Pitcaithly,
1993).
Structure
The CBT treatment process is open and explicit. A contract is agreed at the outset regarding the
number and frequency of sessions offered. Sessions are structured by collaboratively agreeing
an agenda at the beginning of each session, prioritizing, and ensuring that subjects important
to both parties are covered in the available time.
Structure may be even more important for the patient with AS. In AS, deficits in “executive
functioning” affect planning, motivation, organizing and prioritizing. These deficits impose
inflexibility in problem-solving as well as impairing time-perception and management.
Provision of external structure is important to compensate for these. The structure inherent in
CBT may generalize to other areas of the client’s life. “The therapeutic effects of imposing
a greater degree of structure on the client’s day-to-day life via therapy appointments, diary-
keeping ...should not be underestimated” (Hare, 1997).
Motivational and cognitive deficits may require shorter sessions than the usual hour. It can
be mentally exhausting to process all the interpersonal information in a one-to-one setting as
well as the additional demands of “doing CBT”. Conversely, longer sessions may be needed
to allow extra time for slower information-processing or for pedantic longwinded speech
patterns. Typed summaries of sessions for the client to keep may also be useful.
Goal setting
From the formulation and problem list, detailed, specific, objectively measurable goals are
identified. This makes explicit what can be achieved in therapy and provides further structure.
People with AS often identify problems involving deep, existential questions. It is important
to emphasize in concrete terms what can and cannot be achieved, and break goals down into
manageable chunks. One patient initially refused treatment as he saw himself as having AS,

CBT and Asperger Syndrome 297
about which nothing could be done (Hare, 1997). Therapy examined specific current problems
whilst intentionally ignoring the use of the terms “Asperger’s” and “depression”.
Early success experiences maintain motivation – situations perceived as uninteresting or
“impossible” are often met with impatience and frustration by the person with AS. Use of
clear base-line measures and work on a readily attainable early goal can instil hope of further
positive change.
Affective education
An important early stage of CBT involves educating the client about the link between thoughts,
emotions and behaviour. Impairment of emotional recognition in the self and others and in
making social inferences may be a primary deficit in autism and AS. People with AS do
significantly worse than controls on tests of Theory of Mind (ToM, the ability to attribute mental
states to other people) than age-matched controls (Baron-Cohen and Jolliffe, 1997; Heavey,
Phillips, Baron-Cohen and Rutter, 2000; Kleinman, Marciano and Ault, 2001; Rutherford,
Baron-Cohen and Wheelwright, 2002). Non-verbal aspects of emotional expression may be
neither recognized nor displayed by the person with AS. Deficits in ToM may also lead to
paranoid thinking, since the inability to attribute mental states to others means that intentions
must be inferred from behaviour. Well’s CBT model for social phobia may offer techniques
useful in this area (Blackshaw, Kinderman, Hare and Hatton, 2001; Craig, Hatton, Craig and
Bentall, 2004).
This does not mean that people with AS do not experience emotion, but emotions may
be expressed in ways generally considered inappropriate. Suicide may be threatened in
response to boredom or mild distress. One depressed client responded to frustration and
anger with self-harm and heavy alcohol use, seeing this as his only means of emotional release
and communication (Hare, 1997). He was initially unable to make the connection between
emotions and behaviour but learned more appropriate communication skills; for example, he
was interested in the use of his BDI score to express his emotional state.
Difficulty in translating feelings into words may pose a considerable problem. Liane
Holliday Willey, an adult with AS whose adolescent daughter also has AS, describes her
difficulties in discussing emotions (Holliday Willey, 2003). Instead of verbal communication,
her family use instant messaging, e-mail or hand written notes.
Small studies have shown that the reduced emotional vocabulary and the identification
of emotions (in oneself and others) in children with AS can improve somewhat with
teaching (Howlin and Yates, 1999; Bauminger, 2002; Sofronoff and Attwood, 2003). Affective
education may occupy more time in early CBT sessions for a patient with AS. Sessions might
include naming different emotions, discussing why we have emotions and identifying different
levels of emotional expression. Several books, games, videos, interactive CD-ROMs and other
materials are available, aimed at teaching people with AS about emotions (McAfee, 2001;
Moyes, 2001; Silver and Oakes, 2001; Baron-Cohen, 2002).
Comic strip conversations (Gray, 1998) are one means of learning about emotion. Matchstick
figures are drawn to depict a social situation, with thought and speech bubbles to identify
what people do, say and think. Different colours identify emotional content. The colour of
the emotion clarifies the client’s interpretation of events and the rationale for their thoughts
and responses. Alternative responses can be drawn to explore how these will affect other
participants’ thoughts and feelings. Cresswell (2001) describes the use of television soap

298 S. Anderson and J. Morris
operas in CBT with a learning disabled individual to demonstrate links between emotions,
thoughts and behaviour and to explore the effects of alternative responses on those involved
in the situation.
An “emotional thermometer” diagram can be used to demonstrate different levels of emotion
(Sofronoff and Attwood, 2003; Attwood, 2003a, b). Physiological, behavioural and cognitive
cues to the level of emotion being experienced can be marked on the thermometer, together
with warning levels to show when action requires to be taken to prevent further elevation in
emotional arousal, for example relaxation techniques. A fear thermometer was used in the
OCD case study (Reaven and Hepburn, 2003). The child renamed it her “worry machine”.
She used the scale to identify different levels of anxiety caused by her OCD symptoms,
and to develop a hierarchy of symptoms to be tackled with exposure/response prevention.
This technique could be adapted for the development of hierarchies in a range of therapeutic
situations; however, one respondent to my Internet enquiry states:
The idea of an emotional barometer puzzles me, since I don’t modulate emotional responses. This
means that if I am angry, it is full-on, whether the problem is a treacherous personal betray or
getting something stuck in the fax machine ...For me, there is no such thing as a minor annoyance.
I either don’t care and deal with it practically (i.e. take apart the machine dispassionately) or stand
in the office screaming things that would embarrass Venetian gondoliers.
As well as affective education, the person may require education about Asperger syndrome
itself, in addition to information on whichever mood disorder (s)he presents with. Information
on AS should be presented in an accurate and positive light in view of the literal way it is likely
to be interpreted. Attwood suggests reading autobiographies written by others with AS to help
understand their differences and to borrow some of the strategies used (Attwood, personal
communication). The technique of “normalizing” is already commonly used in CBT.
Given that social and environmental items are likely to make up a large part of the CBT
problem list, informing and educating family, friends and colleagues about AS may be a key
task. Personal accounts of disclosure of diagnosis and ways of going about this are provided
by Jackson, 2002 and Shore, 2003.
Thought monitoring
A key component of CBT is monitoring and then challenging automatic thoughts at times
of mood change. Automatic thoughts are the “running commentaries” we make continually
about our situation. We are often barely aware of them, but their content is taken as a true
evaluation of the situation. Automatic thoughts are typically distorted, and each individual has
characteristic patterns of “thinking errors”. Clinical experience suggests that “all or nothing”
thinking is common in AS. It was a prominent thinking error of the child with OCD mentioned
above, with Hare’s depressed client, and in the majority of the clients seen by Gaus (personal
communication). It may be related to the rigidity in AS thinking, and/or linked with the
vulnerability to depression and anxiety disorders. There appears to be no published work in
this area.
People with AS may have qualitative differences in introspection. Non-autistic people report
four categories of inner experience – verbal, visual, unsymbolized thinking, and feelings. When
three individuals with AS were asked to record their inner experiences at random intervals,
experiences reported were predominantly visual, and often in elaborate detail (Hulbert et al.,

CBT and Asperger Syndrome 299
1994). There may be great difficulty in translating such visual thoughts into words in therapy
and, again, writing, drawing and the use of computers may be very useful.
Thought evaluation
Once an automatic thought can be identified, it may be evaluated by listing evidence for and
against the thought being true. A more balanced, functional thought is then developed. This
work can be done on a “Thought Record” (such as Greenberger and Padesky, 1995, or similar
records developed for children and adolescents (Stallard, 2002).
AS is associated with executive functioning deficits (discussed above), problems with
“central coherence” (the ability to see “the big picture”) and procedural learning skills, all
causing problems in generating alternative thoughts, beliefs or solutions, judging the potential
usefulness of alternative strategies, or speculating on the outcome of various courses of action.
If socially inappropriate solutions are generated (Channon, Charman, Heap, Crawford and
Rios, 2001) the therapist may need to take a more directive approach, offering concrete
alternatives backed by logical evidence.
Cognitive impairments inherent in AS may also lead to problems in generalizing skills
learned within the therapy session. This relies on the perception of similarities between
settings. This may be improved by in vivo work in different settings within sessions, and
actively involving a family member or key worker as a co-therapist to support practice in other
settings (Hare, 1997; Reaven and Hepburn, 2003).
Ratings of mood and of belief in the automatic thought before and after challenging it can
demonstrate how a more realistic interpretation of experience improves mood. Hare’s case
study client (1997) was not asked to rate his belief in dysfunctional assumptions as it was
felt that this would cause overwhelming anxiety. In view of his interest in use of BDI scores,
however, belief ratings for automatic thoughts and dysfunctional assumptions may have been
particularly useful.
Sofronoff and Attwood (2003) used Social Stories and Comic Strip Conversations (Gray,
1998) to correct thinking errors in their anxiety management group for children with AS.
The group treated their “poisonous thoughts” (I always make mistakes) with “antidotes” (I
learn more from my mistakes than my successes). It is not stated whether the children met
formal criteria for an anxiety disorder, and ratings of anxiety before and after the intervention
were not used. More detail of techniques and their effectiveness with formal evaluation of the
intervention, with standardized ratings of anxiety symptoms pre and post-treatment would be
helpful.
Attwood (2003b) also suggests using the individual’s special interest to help modify beliefs.
A child with a special interest in Dr Who, for example, is encouraged to imagine how Dr Who
would manage in an anxiety-provoking situation. However, a person with AS comments:
You are dealing with someone who knows a great deal more about this subject than you do, and
they will probably be resentful when it is approached by a therapist as something that can be
manipulated.
Reaven and Hepburn (2003) suggest that challenging beliefs may be less effective than the
presentation of simple, concrete rules. Their patient, although only 7 years old, was apparently
capable of self-reflection and monitoring of her OCD symptoms. However, the authors state
that challenging the irrationality of her beliefs was unproductive. She did effectively set herself

300 S. Anderson and J. Morris
concrete rules such as “None of my business” to control her compulsive “need to know”. This
may reflect her stage of cognitive development rather than the AS.
The client described by Gaus (2003) worked on a paper “thought chain”. He identified
intermediate thoughts between “my room-mate complained that I left crumbs on the counter”
at one end and “I’m going to be homeless” at the other. He found the situation ridiculous, seen
on paper like this, distanced from his thinking and emotions, and decided upon “the weakest
link” in the chain as a target for intervention.
Other cognitive behavioural interventions
The studies already discussed contain several other cognitive behavioural interventions.
Attwood encourages the children to develop an “emotional toolbox” with a variety of “tools”
(behavioural and cognitive techniques) to deal with negative emotions (Attwood, 2003b).
These include a “hammer” (physical tools – exercise), a “paint brush” (relaxation skills), a
“two-handled saw” (social activities, people or animals) and a “manual” (thinking tools –
positive self statements, looking for evidence). He also discusses inappropriate tools such as
violence or threats of suicide.
Reaven and Hepburn’s (2003) child with OCD used an “emotional toolbox”, carrying a
cardboard toolbox and cut-out tools everywhere she went. This may have been useful in
generalizing skills she had learned in therapy. Her tools were relaxation, distraction, positive
self-statements and relabelling of symptoms as OCD.
Discussion
This paper has discussed how clinical experience and the small literature available suggest
that key components of CBT might be useful for patients who have the particular
neuropsychological profile of AS. Subtle impairments in ToM and impairments in executive
functioning are associated with difficulties in tolerating a conventional therapeutic relationship,
in describing emotions and associated thought, in generating alternative thoughts or appropriate
solutions, and in generalizing new skills to everyday settings. Despite these difficulties, the
creative use of CBT techniques does appear promising.
The four published studies in the field used different methods and modifications to CBT since
they were treating different disorders and in different age groups, so it is not possible to draw
any evidence-based conclusions about the general effectiveness of CBT in people with AS. Six
years since the original case studies described were published, the “more carefully evaluated
work” that Hare (1997) hoped for has not been undertaken. More sophisticated experimental
trials are now needed to evaluate the effectiveness of CBT, including computerized CBT in
people with AS and to examine which particular aspects of therapy are effective. Psychological
distress is common in people with AS, and even where this does not reach diagnostic criteria
for a secondary diagnosis, CBT-based techniques might have much to offer in managing such
distress.
Some particular CBT techniques and modifications to “conventional” CBT may inform
good practice in any psychological work with people with AS. These include:
rGreatly increased use of written and visual material in view of the predominantly visual
style of thinking.

CBT and Asperger Syndrome 301
rGreater emphasis on affective education.
rAvoidance of the use of metaphor or abstract concepts in view of the literal, rigid thinking
style.
rA more directive approach than is usual in CBT (and in most forms of psychotherapy)
judiciously used when appropriate.
rInvolvement of a family member or key worker as co-therapist in an attempt to improve
generalization of skills.
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