Cognitive Behavioral Therapy 1
Cognitive Behavioral Therapy and Aspergers Syndrome:
A Case Study
Amy E. Evert
The Ohio State University
College of Social Work
Cognitive Behavioral Therapy 2
Cognitive Behavioral Therapy and Aspergers Syndrome: A Case Study
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
Cognitive Behavioral Therapy 3
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.
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
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
Cognitive Behavioral Therapy 6
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.
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
Cognitive Behavioral Therapy 8
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
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.
Cognitive Behavioral Therapy 10
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
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.
Cognitive Behavioral Therapy 13
Bauminger, N. (2002). The facilitation of social-emotional understanding and social interaction
in high-functioning children with autism: Intervention outcomes. Journal of Autism and
Developmental Disorders, 32(4), 283-298.
Beck, J.S. (1995). Cognitive therapy: Basics and Beyond. NY: Guilford.
Braddock, D.L., & Parrish, S.L. (2000). An institutional history of disability. Disabilities
Brown, M., & Marshall, K. (2006). Cognitive behavior therapy and people with learning
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DeRubeis, R.J., & Beck, A.T. (1988). Cognitive therapy. In K.S. Dobson (Ed.), Handbook of
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Geller, D., Biederman, J., Jones, J., Shapiro, S., Schwartz, S., & Park, K. (1998). Obsessive-
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Cognitive Behavioral Therapy 14
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