CBT, or Cognitive Behavioural Therapy, is a structured, time-limited form of talking therapy that helps individuals identify and change unhelpful thinking patterns, beliefs, and behaviours. In CBT, clients learn to recognise negative thought patterns and develop skills to replace unhelpful behaviours and coping responses.

For autistic individuals, CBT may require adaptations to be neuroaffirming and effective. The therapy focuses not only on changing thoughts but also on developing behavioural strategies, emotion regulation, and social skills, in the context of the individual’s lived experience as an autistic individual.

Why does CBT need to be adapted for autistic people?

While there is research support for the efficacy of CBT in treating anxiety and depression in autistic adults and children, some criticisms of CBT from autistic people include:

  • Feeling gaslit or invalidated, especially when therapists do not understand the autistic experience and apply a neurotypical lens to therapeutic work.
  • Being asked to change thoughts or behaviours that are legitimately connected to real stressors or sensory sensitivities, which can feel dismissive or harmful.
  • The tendency for autistic individuals to mask or camouflage autistic traits during therapy, which can increase exhaustion and burnout rather than addressing underlying issues. When clinicians do not notice their client’s masking behaviors, they might think these behaviors help therapy. However, this may not be the case.
  • The use of abstract language, metaphors, or open-ended questions, which can be confusing or difficult for those who think more literally and concretely.
  • A lack of neuroaffirming approaches, meaning therapy may focus on “normalising” neurotypical behaviours such as eye contact, rather than respecting autistic ways of relating and communicating.
  • Many mainstream assessment tools or rating scales are not developed following consultation from autistic individuals and hence may not capture the nuanced ways autistic individuals experience emotions and thoughts.

Hence, Cognitive Behavioural Therapy (CBT) needs to be adapted for autistic people because their way of thinking, perceiving, and processing information often differs from neurotypical individuals.

Some general considerations include:

  1. Sensory differences: Sensory sensitivities can make therapy settings overwhelming. Adjustments like reducing bright lights or offering breaks can help create a safer, more comfortable environment. A conversation prior to commencing treatment may be helpful to identify any specific adaptations required for the individual.
  2. Masking and camouflaging behaviours: Autistic clients may mask behaviours to fit neurotypical expectations, which can be exhausting and lead to autistic burnout. Recognising and validating their authentic experience rather than pushing neurotypical norms is crucial.
  3. Trauma and Burnout Considerations: Therapists sometimes misinterpret autistic burnout as clinical depression, leading to inappropriate interventions. This highlights the importance of understanding the experiences that can lead to autistic burn out and targeting these collaboratively.
  4. Use of visual supports and structured sessions: Provide visual aids, written summaries, or prompts to assist with executive functioning and difficulties with verbal language processing. Keep sessions structured with clear agendas to prevent tangents and help manage attention.

What specific ways can therapists adapt CBT?

  1. Therapy Structure and Pacing: Clear structure, predictable sessions, shorter or flexible durations, and regular scheduling of sessions facilitate assist the client with a sense of control and predictability.
  2. Recognise differences in cognitive styles: Autistic individuals may think more literally and concretely, finding metaphors or abstract concepts confusing. CBT should use clear, concrete language and examples from their lived experience.
  3. Assessing and addressing alexithymia and interoceptive difficulties: About half of autistic people have challenges identifying and expressing emotions. More groundwork may be needed to establish emotional literacy and body awareness.
  4. Focus on behavioural strategies: Since cognitive shifts in thinking styles may be challenging due to rigid or literal thinking, greater emphasis on behavioural interventions like skill-building, social communication skills, emotion regulation, and problem-solving may be more helpful.
  5. Recognise and validate experiences: Do not invalidate valid autistic perceptions or feelings by pushing neurotypical interpretations. Avoid assuming negative thoughts are irrational when real environmental stresses or systemic barriers exist.
  6. Consider incorporating additional therapeutic modalities when useful such as methods informed by Dialectical Behaviour Therapy (DBT) or Acceptance Commitment Therapy (ACT).

Overall, adaptations aim to create a safe, validating, and empowering therapeutic environment that respects autistic identities and meets their specific cognitive, sensory, and emotional needs.

To access psychological services that are sensitive to the needs of autistic individuals and their families, please enquire today.

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