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					                                         Cognitive Behavioral Therapy 1




Cognitive Behavioral Therapy and Aspergers Syndrome:

                   A Case Study




                   Amy E. Evert

             The Ohio State University

               College of Social Work

                   Autumn 2006
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               Cognitive Behavioral Therapy and Aspergers Syndrome: A Case Study

Introduction

       In 1990, the Americans with Disabilities Act (ADA) was passed with the efforts of

political activism in mental health, physical, and sensory disability rights groups (Braddock &

Parish, 2000). The Americans with Disabilities Act outlines the rights, inclusion, and equal

opportunity for people with disabilities. Historically, people with disabilities have been

perceived as “defective.” Society did not believe people with disabilities were able to function

as productive members of society. However since the civil rights movement in the 1960’s, there

has been a paradigm shift in terms of the potential abilities and societal perceptions of people

with disabilities. Today, government programs work toward the goal of total

inclusion/mainstreaming for people with disabilities. It is now the standard for people with

disabilities to be included in mainstream schools, provided supports to function in the

community, and occupy positions of employment. This belief holds true in terms of treatment

approaches to help people with disabilities as well. This paper will discuss the case of a young

adult, male with a diagnosis of Aspergers Syndrome. A cognitive-behavioral approach will be

implemented in individual counseling to address the specific issues of the client.

       For the purpose of confidentiality, the client will be referred to as Hank to disguise his

identifying information. Hank will be receiving individual therapy through services offered by

the Nisonger Center at the Ohio State University. The Nisonger Center is an academic training

and research facility aimed at addressing the needs and concerns of the MR/DD population. In

this particular case, Hank’s Mom contacted Thomas Fish, PhD, LISW, who is a well-respected

program developer and researcher in the field of MR/DD. Dr. Fish has a special interest in the

adjustment and adaptations of people with disabilities when transitioning into adulthood. Hank’s
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Mom was concerned about Hank’s current level of functioning and felt fearful about the future

of her son. These parental concerns are reflective of Little and Clark’s (2006) findings that

parents of a child with apsergers syndrome often report their most pressing worry as focusing on

adulthood and the future of their’ children. Dr. Fish invited Hank’s Mom to the center to discuss

her concerns and the linkage to appropriate services.

Case Summary

       Hank is a 21-year old male who grew up in an upper-middle class household located

Northwest of Columbus, Ohio. Hank is Caucasian, single, and unemployed. His Mother and

Father are supports in his life, however they are divorced, which reportedly occurred when Hank

was in the 6th grade. He had two siblings, an older brother and younger sister. Hank has lived

with a diagnosis of Aspergers Syndrome since he was two years old. Hank grew up in the public

school system and was mainstreamed with typical developing children. He decided to attend

college after receiving his high school diploma. He attended Bowling Green college for two

years and has some trouble adapting to his school environment. After the completion of his

sophomore year, Hank returned home to live with his mom and younger sister. Hank reports that

he enjoyed his college experience despite his ongoing struggle with obsessive thought pattern

and over-stimulation by outside stimuli, such as the social demands of college life. Hank reports

that he enjoyed dorm life and classes. Hank does not have many friends or social supports

outside the home.

       Hank is a very nice individual. He does have some obsessive thinking patterns and might

benefit from a cognitive behavioral approach to therapy. He does have some experience with

behavioral intervention due to the nature of his disorder and the treatment strategies used to treat

the symptomology of the syndrome. Hank identifies his chief concern as being his current
                                                                 Cognitive Behavioral Therapy 4


situation of unemployment. Hank’s strengths include a happy demeanor, moderate level of

insight, and diverse interests. He appears to be motivated to engage in the therapeutic process

with the hopes of better adaptation to the demands of adulthood. Treatment recommendations

are to challenge Hank’s automatic thoughts about failure and poor self-concept, to link him with

the Aspirations program to further his development of vocational skills, and to improve his

interpersonal skills.

        Hank’s diagnosis of Aspergers syndrome is categorized as a Pervasive Developmental

Disorder (PDD) emerging in the early years of childhood. Pervasive Developmental Disorders

are usually identified between the ages of two and three years old. Aspergers syndrome is

considered pervasive, which means it affects multiple aspects of functioning including language

development, gross motor and fine motor, the ability for the child to relate to his or her

environment, social interaction, and behavioral adaptability. Social impairment is a core deficit

of PDD diagnosis and therefore it is critical to address in the treatment process (Bauminger,

2002). Social isolation is a predominant concern with people diagnosed with Aspergers

syndrome. Clinicians need to assess suicidal ideations in this group. This population is at risk

for repeated serious social failures and feelings of isolation, which are psychosocial predisposing

factors to attempted suicide in youth with Aspergers syndrome (Zasshi, 2006).

        Only recently have studies emerged to focus on the needs of people with a PDD

diagnosis. Bauminger (2002) outlines two components of goal development when implementing

Cognitive Behavioral Therapy (CBT) with this population. First, the practitioner must work to

broaden the person’s understanding of other’s mental states. Secondly, the practitioner must

teach the individual to mediate and directly guide their knowledge in applying knowledge to

enhance reciprocity in daily social interactions. It should also be noted that many times anxiety
                                                                 Cognitive Behavioral Therapy 5


disorders and Obsessive Compulsive Disorder (OCD) personality traits are co-occurring in PDD

clients (Sofronoff, Attwood, & Hinton, 2005). Sofronoff et al. (2005) found CBT to be

successful in reducing the anxiety symptomatology and increase strategies to deal with anxiety-

provoking situations in this population.

       Parent involvement with individuals with Aspergers and other PDD spectrum disorders

has been documented extensively. Training parents as part of the intervention team can be an

effective modality in the promotion and generalizability of acquired skills to daily activities

(Solomon, 2004). Since PDD diagnoses are most commonly identified in the early years of life,

most families are linked to early intervention and intensive behavioral treatment programs

immediately. These interventions and treatment plans for children with PDD are accustomed to

being involved and participatory in their child’s treatment. The Sofronoff et al. (2005) study

found parent involvement in CBT to be beneficial to the child as well as the parent themselves.

The parent and child benefit due to both participants feeling more competent in the treatment

program, the parent is able to assist the child better, and the parent is able to empower other

parents with similar experiences.

Cognitive Behavioral Therapy

       Psychologists, Aaron Beck and Albert Ellis, developed the Cognitive Behavioral Therapy

(CBT) model. CBT is actually a fusion of “a number of related therapies that focus on

cognitions as the mediator of psychological distress and dysfunction” (Vonk & Early, 2002, p.

115). The model draws on behavioral therapy, as well as cognitive therapy. “The heuristics and

therapeutic value of the cognitive model lies in its emphasis on the relatively easily accessed,

preconscious and conscious, mental events that the clients can be trained to report” (DeRubeis &

Beck, p. 273). The cognitive triad is a tool sometime utilized in cognitive therapy. This triad is
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characterized by the beliefs reported by the client. The beliefs are then examined as pertaining to

the client’s views of him or herself, the future, and the world. Cognitive therapy is based on the

belief that most disturbances arise from faulty information processing and the goal of treatment

is to correct these faulty cognitions and dysfunctional beliefs, and replace them with positive,

realistic beliefs (Vonk & Early, 2002).

       Beck (1995) outlines the basic structure of a cognitive behavioral session as follows: At

the beginning of the session, the practitioner should facilitate a brief update of the current status

of the individual; this includes a rating of mood and a check in about medication compliance if

applicable. The practitioner then needs to bridge a connection from the previous session, set an

agenda for the current session, and review the past week’s homework assignment. The

remainder of the session will be designated for the discussion of issues, setting a new homework

assignment, and providing feedback between practitioner and client. The practitioner will

occupy the role of the teacher and guide. His or her role will be to teach the client the

relationship among cognitions, as well as assist the client in the identification, examination, and

alleviation of maladaptive thoughts and beliefs. Professionals refer to this process as cognitive

restructuring (Vonk & Early, 2002).

       The ABC model is a strategy used in CBT to teach the client about the relationship of

thoughts, emotions, and behaviors. The “A” represents the activating event that causes an

emotional or behavioral consequence. “B” is the belief or attitudes the person holds in regards to

the activating event. “C” is the consequence or outcome response to the event, which is

significantly influenced by the beliefs or attitude the person holds in regards to the activating

event. The client needs to be able to identify his or her thoughts or beliefs, including

expectations, self-efficacy, self-concept, attention, selective memory, attribution, evaluations,
                                                                Cognitive Behavioral Therapy 7


self-instruction, hidden directives, and explanatory style. CBT techniques to identify these

thoughts and beliefs include the Daily Record of Dysfunctional thoughts and the downward

arrow technique (Vonk & Early, 2002). Homework assignments are an element of CBT used to

extend the learning process beyond the therapy session. The ultimate goal is for the client t o

gain the skills necessary to examine and replace maladaptive cognitions with more realistic or

positive ones, which will in turn influence and/or change the behavior of the individual.

Practice Implications

       When Hank first came to see me for individualized therapy, he presented anxious and

unsure. Together we addressed the nervousness and clarified some expectations of therapy.

After time passed, Hank became more engaged in the therapeutic process. Hank told me about

his college experience at Bowling Green and the chain of events leading to his return home. It

was clear that Hank had some obsessive thought patterns about various stimuli in his school

environment. For example, Hank became fixated on the graveyard located on the college

campus. Hank often found his thoughts preoccupied with the graveyard and he would make the

point to walk by the graveyard late at night on Friday and Saturday nights. Toward the end of

Hank’s second academic year, he started having obsessive thoughts about a girl classmate that

gave him positive feedback after a presentation he did in class. This obsession was a pervasive

thought that consumed Hank’s mind and became a common subject of conversation with close

family members such as his mother and sister.

       Hank has issues connecting and building relationships with others. He has a close bond

with his mother and otherwise, does not interact with other except in a superficial manner. A

core deficit associated with Aspergers syndrome is an impairment relating and forming

meaningful relationships with others. Solomon, Goodlin-Jones, and Anders (2004) describe
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these idiosyncratic ways of perceiving and understanding emotions as stemming “from the lack

of components of action and reaction necessary for the development of reciprocal, affectively

charged interpersonal relationships with others” (p.650). The theory of mind is a helpful tool

when trying to empathize with the experiences of individuals with Aspergers. People with

Aspergers many times lack the ability to understand the different perspectives and emotions of

others.

          When applying the CBT model to Hank’s situation, there are multiple goals to keep in

mind in the treatment plan. In addition to theory of mind factors, executive functioning,

including goal direction, motivation, and organization, and emotional awareness should be taken

into consideration when developing goals. Hank’s attainment of such skills will assist him in

many aspects of functioning. By improving his theory of mind, executive functioning, and

emotional awareness, Hank will adapt the skills critical to develop relationships and engage in

meaningful interpersonal interactions. This therapeutic goal will enhance his personal

relationships, as well as the demands of an employment position.

          Hank’s obsessive compulsive thought patterns are another focus of therapy. Obsessive-

compulsive disorder is “ an anxiety disorder characterized by intrusive thoughts, images, or

worries (i.e. obsessions) and/or repetitive, nonfunctional behaviors that emerge in an effort to

quell anxiety (i.e. compulsions)” (Reaven & Hepburn, 2003). Recent studies focusing on OCD

in children have found that 70 percent of children with OCD have at least one comorbid disorder.

This co-occurrence often happens with neurodevelopmental diagnoses, such as ADHD,

Tourette’s syndrome, Aspergers syndrome, and autism (Geller et al., 1998).

          Reaven and Hepburn (2003) offer guidelines to CBT techniques when working with the

Autism Spectrum Disorders (ASD). Helpful techniques include externalizing OCD symptoms,
                                                                  Cognitive Behavioral Therapy 9


mapping the OCD symptoms, which means the individual will engage in a self-observation

process of becoming aware of how much time the person is engaging in the OCD behaviors. The

client will record when OCD symptoms happen and possible strategies to cope with the

behavior. The authors suggest establishing a hierarchy in which the client will arrange the least

to most distressing conditions. Goals should be negotiated at the start of therapy and

continuously re-evaluated throughout the process of therapy. Visual supports may be helpful

modifications for the ASD population. Exposure and response prevention (E/RP) is another

effective strategy to use when confronting a feared stimulus and then utilize response prevention

to block the ritual response. In E/RP, the client labels the anxiety, tells him or herself that they

can “beat” it, and try to distract them from the response provoking stimuli.

       Hank has decided he would like to try CBT and appears motivated for therapy. Hank has

identified his goals as to learn more interpersonal skills to better engage in positive interactions.

Hank believes this goal will help him to attain a job and maintain a position of employment.

Secondly, Hank would like to increase his emotional understanding of others, which includes

managing feelings and broadening his repertoire of emotional response. Last, Hank

acknowledged his need to adopt more social problem solving skills to be a goal. Hank has

agreed to attend 12, one-hour sessions for the next twelve weeks. It was beneficial for Hank to

have me set-up a metaphoric analogy to what we will be working on in therapy. For the sake of

better understanding, I created the scenario of us being scientists who will be exploring a new

planet. This metaphor helped Hank to step outside himself and take the role of an observer in

order to assess his cognitive functioning more effectively.

       The first three sessions were outlined as follows: each session has a different focus. The

first session, Hank was asked to explore the positive emotions such as happiness and relaxation.
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The second session was designated to explore anxiety and recognize when change occurs in

physiologically, thinking behavior, and speech. Hank and I discussed the concept of a tool box

to fix “the feelings” with a focus on physical tools that provide a constructive release of

emotional energy, such as running or playing a sport. We also discussed relaxation tools that can

be utilized when confronted with an anxiety-provoking situation. Hank’s homework assignment

for week two was to complete a Daily Record of Dysfunctional Thoughts. This assignment will

help Hank to identify his thoughts and beliefs, which is a critical component of CBT. During the

third therapeutic session, Hank and I focused on the aspects of social tools. We explored the

thermometer approach to measuring the degrees of emotions. In the third session, Hank

extended his understanding of social interactions through the use of social stories. Hank and I

read social stories concerning with the coming of age during adulthood, the expectations of being

an adult, and appropriate adult behavior.

       Hank and I have completed three session of therapy. So far Hank seems to be very

responsive to the CBT model. He has successfully engaged in the process of cognitive

restructuring by identifying, examining, and alleviating maladaptive thoughts and beliefs. He

continues to be motivated in therapy and is willing to continue to work on his stated goals. The

treatment plan is for Hank to adapt more skills to counteract some of his cognitive deficiencies.

He and I will use some behavioral rehearsal/ role-playing to confront possible scenarios he may

encounter in his work environment and interpersonally. Other techniques we will use in the

intervention process include self-instructional training for self-regulation, interpersonal problem

solving, and environmental problem solving.
                                                                 Cognitive Behavioral Therapy 11


Issues of Diversity

       “People with disabilities have shared a history that has often been oppressive and

included abuse, neglect, sterilization, stigma, euthanasia, segregation, and institutionalization”

(Braddock & Parish, 2000, p.89). In order to assess people with disabilities, practitioners need to

be sensitive to these realities in order to effectively use the CBT model in treatment. The

approach may need to be applied differently in this group to take into account any cognitive

impairment as well as supportive needs (Brown & Marshall, 2006). Norman (1996) developed a

culturally sensitive implementation model of cognitive therapy, which can be applied when

assessing people with disabilities.

       Norman’s cultural assessment evaluates the biopsychosocial aspects of the individual to

monitor when implementing CBT. Biological, environmental, and psychological influences are

examined cooperatively with cultural dynamics of disability culture. The biological/cultural

component addresses the individual’s beliefs/views of the body, thoughts about medications,

gender, and other physiological variables. The environment/cultural assessment explores family

constellation, socioeconomic status, and other institutional influences, such as ableism. Linton

(1998) defines “ableism” as “discrimination in favor of the able-bodied” (p.8). The

psychological/cultural component examines prejudice and discrimination experienced by the

client, spiritual beliefs, cognitive schema, and education variables. When this model is

exemplified in therapy, the practitioner will be more competent to address the issues of diversity

in the treatment process. (See figure 1.1 for further illustration of Norman’s model)
                                                                  Cognitive Behavioral Therapy 12




                Biological                 Environment                   Psychological




                 Culture                      Culture                         Culture




a. View of the body                    a. Family constellation        a. Prejudice/discrimination

b. View of medication                  b. Socioeconomic status        b. Spiritual beliefs

c. Gender                              c. Institutional ableism       c. Cognitive schema

d. Disability                                                         d. Education variables

Figure 1.1 Norman (1996) Culturally Sensitive Implementation Model of CBT

Conclusion

       Cognitive-behavioral therapy has proven to be an effective intervention for people with

Asperger syndrome. Hank is a high-functioning individual in terms of cognitive, social, and

emotional abilities. The treatment thus far has appeared to meet his needs. Hank is acquiring

skills to better self-monitor his thoughts and emotions. He has shown significant progress in

terms of learning CBT. However with Hank’s specific diagnosis, it was helpful to keep

teachings of therapy simple and concrete. Visual tools were helpful for Hank’s comprehension,

such as the ABC chart and emotions thermometer. He continues to stay engaged in therapy and

motivated for positive change. It is evident in the research that there is further need for studies

focusing on the effects of CBT therapy with people with disabilities. Existing research focuses

predominantly on the outcomes of children, thus it would be advantageous to study the adult

community more closely.
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                                            References

Bauminger, N. (2002). The facilitation of social-emotional understanding and social interaction

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Beck, J.S. (1995). Cognitive therapy: Basics and Beyond. NY: Guilford.

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Brown, M., & Marshall, K. (2006). Cognitive behavior therapy and people with learning

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Geller, D., Biederman, J., Jones, J., Shapiro, S., Schwartz, S., & Park, K. (1998). Obsessive-

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Linton, S. (1998). Claiming disability: knowledge and identity. New York: New York University

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                                                              Cognitive Behavioral Therapy 14


Sofronoff, K., Attwood, T., & Hinton, S. (2005). A randomized controlled trial of a CBT

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