In this month’s reading group we had a really interesting discussion about the effectiveness of CBT for autistic people and how we evaluate therapies. We provided an interesting reading and some discussion questions:
- Why are there such variations in ratings of the effectiveness of therapies?
- How can we adapt the way we evaluate the effectiveness of therapies?
- Does anyone know of any alternative treatments to CBT that are effective for autistic people?
- Any experience/ideas of successful modifications/adaptations to CBT to make it more effective for autistic people?
Access to therapies
We discussed how many autistic and neurodiverse adults find that CBT is not always the most appropriate therapy even though it is the most commonly provided by the NHS. One person felt that there can be a fight to get support for mental health conditions because they can be overlooked for people with an autism diagnosis: this meant that people lost faith in getting the right support at the right time.
The article raised the interesting finding that parents rated CBT as more effective for younger children. Could there be a link between early intervention and effectiveness – that older children have waited a long time for support and as a result, their anxiety has escalated so much that they benefit less?
CBT is a treatment aimed at the individual, but one person felt that we also need to consider the social model of disability. Some causes of anxiety might be because the person’s needs are not being met. We need to ensure that we are providing support and adaptations around the autistic person and not just expecting them to change their thinking to fit the neurotypical world.
Most therapies offered on the NHS reportedly have a time limit of around 6 weeks. People felt this was problematic because autistic people can need longer than other people to build rapport with their therapist. One person explained that a clinician might think a child hasn’t engaged in the therapy, but as a parent, they felt the child was just getting used to the setting.
Evaluating the effectiveness of therapists
We agreed this depends on the individual and clinician – there is not a one-size-fits-all measure of success. Positive experiences come when clinicians have made adaptations to help. There are some good examples of adaptations in the NAS good practice guide. It depends too on what the person wants to get out of therapy: managing expectations and defining success seems important.
Effectiveness is also likely to be a product of willingness. The voice of the child is very important in therapy. There are different ways to help enhance the child’s voice. A good example of this is the Digital Stories work being down at ACoRNS Soton and ACoRNS Sussex – this can help them to show and express their experiences in day to day life.
One group member wondered how masking may affect CBT: If the client knows the aim of the therapy, they may try to act in a certain way to meet these aims. This could mean it’s harder to transfer these skills into everyday life. The context of behaviour is crucial: practitioners only see a child for a limited time in a session so they may not be able to see beyond any masking. We raised the question: how accurate is the practitioner’s evaluation if they are not able to see past this?
Autism is sometimes seen as a difference in Central Coherence (a focus on detail rather than ‘big picture’). This focus on specifics might make the generalisation of behaviour to everyday life more difficult in autism. Similarly, executive function differences might affect how well autistic people can apply techniques in CBT. What ways could therapists adapt their practice to address this? One key take-home from our recent Zoom or Room project was that online sessions can help give the therapist greater insight into their client’s home life and family, which can help inform their work. Sessions taking place in the home via Zoom may also help in generalising the strategies, as they learnt in a familiar setting.
We looked at the different ways the NICE guidelines suggest adapting CBT. For example, using a child’s special interests can be a great way to help engagement. However, this is a balancing act: one person reported that using such interests can become overwhelming and cause over-excitement. This is where parent involvement can be really important, e.g. in predicting how the child would react. Parent involvement can also help the child in applying the techniques to different circumstances.
We spoke about the importance of training – all the adaptations in the world won’t work If the practitioner does not have the appropriate autism training. Many people in the group felt that there is often a lack of autism-specific knowledge. As one person mentioned, mental health problems are common in neurodiverse people – a study in 2019 found 74% of autistic people reported that they had reached out for mental health support in the last five years. Autism training for practitioners is therefore really important. A good example is the CYP-Improving Access to Psychological Therapies (IAPT) ASC/LD postgrad diploma at Exeter University . This trains practitioners (often from Child and Adolescent Mental Health services) in evidence-based psychological therapies for young people with autism and/or learning disability. These therapies include as well as adapted CBT. Another good local example is the Time for Autism programme at Brighton and Sussex Medical School which provides specific autism training for students in their 4th year of study – including visits with local families with autistic children.
Alternatives to CBT
CBT won’t be the best fit for everyone. A group member highlighted it can be damaging for self-esteem if CBT doesn’t work for them. We discussed other approaches such as ACT (acceptance commitment therapy) and mindfulness. Someone talked about how medication, while a controversial topic, can be useful for some, for example in bringing anxiety to a lower level where the client can then access therapies.
How has the pandemic shaped the delivery of online therapies?
Since the beginning of the COVID pandemic, many services have used online sessions in some circumstances. We discussed how this should be kept as an option, but it comes down to personal preference and experience. For some, being in their own space can be much more comfortable. It also removes the stress of travel and the potentially overwhelming environment of the clinic. However, we spoke about how it can be harder to build rapport, which can make it hard to engage fully in online sessions. We talked about how hard it can be to read body language online and to manage after the session, with no separation in time and space between the session/clinic and home life. We all felt it is important that an initial conversation takes place between the client and practitioner to develop the right treatment plan. The recent Zoom or Room project highlighted how online sessions can be a real opportunity to have more client voices and give them the chance to input into how their therapy happens.
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