What are some practical and environmental considerations when working with autistic clients, e.g. where and when you see people?

-          Ask the client for details of sensory difficulties e.g. lights / noise, can be helpful to stick to the same room or time each week.

What are some helpful adaptations with your use of language?

-          Avoid metaphors and over-use of Socratic dialogue

What are some ways you can adapt CBT with autistic clients?

-          Develop personalised ways to explore emotions together (e.g. body maps)

Any other key learning points?

-          Ask the person for their preferences – don’t assume!

Any questions for Ailsa?

-          How would we incorporate special interests into CBT specifically?

-          Seeing people at the same date and time each week – avoid changing schedule

-          Be aware of bright lights/ noises/ temperature in the room

-          Ideally see people at the same room for all of the sessions

What are some helpful adaptations with your use of language?

-          Using less open questions

-          Modify language to fit with the individual

-          Check understanding of each other

-          Less socratic dialogue

-          More closed qs

-          Avoid using metaphors/ abstract language

-          Don’t assume expressive and receptive language are the same level

-          Don’t assume fluid and easy social interaction  

What are some ways you can adapt CBT with autistic clients?

-          Develop individual scale of the emotional experience

-          Use visual tools to map bodily sensations

-          Rate emotions focusing on internal experiences and practice rating as often as possible

Any other key learning points?

-          Each person is different and the approach to treatment needs to be individualised

-           

Any questions for Ailsa?

-          If someone suspects a potential diagnosis of autism and they see us for SAD treatment, what are the things we need to be aware of? Are there any limitations/ adaptations when applying the standard CBT protocol?

Helpful adaptations to language: Say what you mean and use concrete language. Don't use jargon or metaphors or if you use metaphors use one of their special interests.

Adapting CBT: Use more visual aids and spend longer at assessment to get to know what adaptations they need. Spend time creating a scale of emotions so that they can express them easier.

Any other learning: Give them longer to respond rather than assuming they don't understand. Throwing more words at them will mean they will need longer to process.

Question: Can we do any thought work with clients with autism? If so, how can we help thoughts feel less abstract and easier to identify/work with?

-Overall sensory aspects of clinical environment – lighting, temperature 

-Online environment – busy background on screen/noises 

What are some helpful adaptations with your use of language?

-Develop shared vocabulary

-Less Socratic dialogue

-More closed questions

-Use visual cues/imagery

What are some ways you can adapt CBT with autistic clients?

-May need to use techniques that are more concrete, such as behavioural change, or use of visual images  

-Asking people to recall thoughts may be too abstract

-Feelings – noticing and describing feelings may be difficult. Increasing awareness of emotions may be needed before starting more abstract techniques. 

Any other key learning points?

-May be helpful to spend time on emotions psychoed before starting interventions

-Be aware that more repetition may be needed for consolidation

-Behaviour change may need to be taken at slower pace with graded steps

Any questions for Ailsa?

-Any tips for treating GAD when protocol is mostly self-guided by homework/less active sessions and homework is mainly around catching thoughts?

Giving clients more time and space to reflect and provide answers, using less Socratic dialogue.

I can adapt sessions by offering more visual materials. The use of body maps/ scale can be helpful for clients to be able to explore emotions and understand how their emotions work.

Always ask client about their preferences,

Adaptations to language: avoid jargon, use concise and clear language style, base metaphors around special interests or do not use them where possible

Other learning: can be helpful to have open discussion early on with clients to identify how we are able to adapt sessions to them, how much they identify with their ASC and what they would like to gain from treatment

Questions: how to work with SAD in ASC, particularly when avoiding working with cognitions?

- Consider sensory environment both in person and online – sounds, temperature, light.

- Try to keep structure and routine consistent e.g., appointment time and room.

What are some helpful adaptations with your use of language?

- Use concrete language, plain English, avoid excessive use of metaphors, ambiguity and hypothetical situations.

- Make space and time when communicating for processing; delay in answering questions or asking further questions.

- Consider more directive language and closed questions or forced choice rather than lots of open questions.

- Check understanding.

Any other key learning points?

- Consider visual aids or cues used in a developmentally appropriate way – remember autism is heterogeneous.

Are there any additional resources that can be helpful for the client?

- Consider involving family members, partners or carers if the client agrees.

What are some ways you can adapt CBT with autistic clients?

- Consider placing greater emphasis on changing behaviours than cognitions.

- Consider enhancing emotional literacy prior to change elements – creating individualised rating scales e.g., using body maps and practice using this for noticing changes in intensity.

Any questions for Ailsa?

- Any suggestions/alternatives to using metaphors to explain rationales in CBT would be really helpful (there are quite a few! e.g., linen cupboard/conveyor belt for PTSD, builder's apprentice for behavioural experiments etc.)

• aim to use same room, same date/time of sessions, check how they find the lighting/noises etc

Language adaptions:

• Avoid metaphors, can be more directive, less open Qs more closed Qs

CBT adaptions:

• Use more visual aids like a body map when describing emotions/sensations, check out how they describe it, more emphasis on behavioural change, longer processing time

Other learning points:

• Take time to check in with their relationship with/view of their autism and don't assume anything especially because it is highly heterogenous

Questions:

• There is a lot of misinformation on social media at the moment around autism/adhd e.g. 'if you sleep with your hand in this position then you are autistic' and then people self-diagnosing. How would you respond to clients who bring this type of thing?

-          Ask the client about sensory challenges e.g. lighting, temperature of the room, room layout, noise, keeping to the same room to help with routine

-          For online sessions, to ensure that background noise is minimal and adjusting the screen accordingly.

Language adaptions

-          Avoid jargon or metaphors

-          Asked the client about what preferred vocabulary they like to use.

-          Use of more closed questions

-          Do check with the client of their understanding.

-          Use simple language.

Adapt CBT for autistic clients

-          Make use of visual aids.

-          Ask the client what their preferred way of information taking and understanding is- don’t assume!

-          Give longer time for the client to respond.

-          Ask what is their preferred way of giving ratings e.g. using numbers, words, visual, traffic light, emotion charts.

Any other key learning points

-          Spend a good chunk of time understanding the clients needs and adaptions, and what works best for them. It is okay to have a conversation early one to see how they identify with their autism, and gain an understanding from them on what will work best to get the best out of treatment.

- Easy client is different so the adaption will is not universal to all- ask the client what would be helpful.

Question

-           How would you introduce NATs with a client with autism and make it feel less abstract for them? I have found it difficult to find resources around this, so any suggestion or recommendations on resources would be really helpful.

Helpful adaptations to language: This requires a discussion with the client but it may be useful to be direct in communication and reduce metaphors. Questions can be reframed. Examples may need to given as a preface to questions regarding the client's experience of something

Ways to adapt CBT: Written information can be adapted to be simpler and include visual cues. Outcome measures may also require some psycho ed or discussion. In session demonstrations may need to be used more. Behavioural work focused on

Other key learning points: Using a client's interests to explain key concepts can be a great way to get them across

Questions for Ailsa: Any examples of how to get client's social network involved in therapy (consensually)

Try and also leverage a clients special interests to convey psychological concepts in a meaningful and engaging manner.

Helpful adaptations to language: avoiding the use of over-explaining or multiple questions at once. Don’t use metaphors or phrases. Also, use more specific or closed questions compared to open questions.

Adapting CBT: adapt materials to ensure they are simple to understand (consider using pictures). Use more psycho-ed and individual scales for emotions to help monitor the clients progress. Ask the client what has worked well for them previously, or a close family member if permission is given, to see what has been helpful/unhelpful in past experiences.

Any other learning: Spend time on emotions psycho-ed before interventions – reviewing their understanding. Don’t assume anything – autism is heterogeneous. Spend time understanding the clients needs and adaptations. Consider placing more emphasis on behavioural vs cognitive work.

Questions: How do you manage the self-diagnosis of autism/adhd? – there is a increase on this, especially from tiktok etc

Make sure things are structured for the client e.g. sessions offered on the same day, time, location, therapy room, ensure there are reminders for them. Think about the environment they are in and sensory impacts – are the lights too bright, are there loud sounds (maybe something we wouldn’t usually notice e.g. clock ticking), is the room cool, be mindful visual backdrop if online

What are some helpful adaptations with your use of language?

No metaphors, be mindful of how clear our language is, more closed questions, more visual cues to help

What are some ways you can adapt CBT with autistic clients?

Spend more time at assessment understanding the adaptations they will find helpful. Be mindful of our usual communication style, both verbal as above & non-verbal e.g. leaning in & eye contact.

Find a shared communication – use of an individual scale of the emotional experience

Make sure CBT foundational skills are in place – give more psycho-education if helpful

Use more visuals

More of a behavioural focus in treatment

More time supporting them to plan homework & help them to generalise this across situations, increase practices

Any other key learning points?

Remember the heterogeneity of the disorder and that no size fits all.

Give clients more time to respond, don’t jump in with further questions

Any questions:

Within depression would we use much thought work? If so, how to adapt it to make it seem less abstract to identify and work with?

• Think about the clinical environment and the sensory aspects – ask the patient what would work best for them.

• Stick to a good routine and therapy structure e.g same time, day, room, agenda

• There is a pre-treatment form that can be used to confirm the autistic persons’ preferences on how therapy will work

• Give a balance of verbal and visual information

• Use a body map to help identify and locate physical sensations and use an intensity rating scale

• Don't need to force things like eye contact/leaning in to listen - some people with ASD may not be comfortable with this

 Noise level in clinic space, being mindful of temperature levels in room and how bright the lights are.  Using the same room if possible, appointments being the same time and location.

What are some helpful adaptations with your use of language?

 -Not using excessive metaphors, using concrete and clear language. Allowing space and time for individual to respond to questions .

What are some ways you can adapt CBT with autistic clients?

-Being visual-using visual images and materials

- Being more directive

- Using more therapist modelling in sessions

Any other key learning points?

-Understanding individuals needs as this can vary in terms of what adaptations may  need to be considered.

-Can also be helpful to bring in individual's special interests to make this more meaningful for them and concrete.

Any questions for Ailsa?

When might it be more helpful to introduce thought work for Depression, and how to adapt this if needed.

• Be aware of autistic client's sensory difficulties, consider how the room is set up, the noises and lightening

• try to keep the same room each time

• be consistent on session time

Helpful adaptations with the use of language:

• keep it direct and simple

• less use on open questions, use of closed questions

• check with client the terms they prefer to use

Adapting CBT with autistic client:

• be visual

• create individual body scale to elicit and measure emotion

• allow pauses for client to process questions

  
  

  Other learnings:

• keep in mind the autism presentation can be varied, there is no one-size, be flexible in gathering individual needs for adaptation

• CBT is helpful for autistic client

• Autistic individuals has difficulty with social interaction and they do experience depression and anxieties.

  
  

  Questions for Ailsa:

• Any tips on how to manage autistic client's frustration in the session if it happens?

• how to navigate the involvement of carer in the therapy?

  
  

  Thanks

  
  

- Having structure and routine: having the same schedule e.g. same room/ time/location of appointment to help.  

- To not force eye-contact and quieten down on our non-verbal cues.

- Ensuring that I am not speaking fast and allowing extra time to help them process the information.

Environmental:

- Creating a safe quiet space for the client.

- It might be helpful to also consider seating, so they have enough personal space, and are not sat infront of something that can be overly stimulating e.g. facing a window where they can see busy roads.

What are some helpful adaptations with your use of language?

- Taking into consideration their individual differences. The terms referred to autism can be different and the symptoms so asking patients about this. Using clear language when communicating and avoiding metaphors. Developing shared understanding of vocabulary.

- Making use of visual materials.

- Language needs to be clear and concrete - simple and straightforward language and avoiding the use of abstract terminology.

- Using the same/similar words and keeping this consistent.

What are some ways you can adapt CBT with autistic clients?

- Similar to above, keeping the sessions structured so client are not surprised by what’s to come.

- Using visual cues and individualised approach

- Mapping bodily symptoms to develop individualised rating scale.

Any other key learning points?

- Asking about whether autism has any impact in their life.

- Finding out clients special interest and applying that in session e.g. if they are interested in music - notes go up the scale to help them think about the ratings.

-        Lighting

-        Sounds

-        Same time and room each week

-        Temperature

Language adaptations:

-        Avoid jargon

-        Be more directive

-        Shared language

-        Less open questions

Adaptations for CBT:

-        More sessions

-        More visual aids

-        Time to process information

-        Map body symptoms

Other learning points

-        Remember everyone is different

-        Ask about their autism e.g., what it means to them, preferred terms etc.

• limit schedule changes if possible

• being conscious of light and sound in the room/waiting room.

• keeping the same room each session

What are some helpful adaptations with your use of language?

• less open-ended questions + more closed questions

• more direct language

• limiting metaphores

• using imagery/more examples

What are some ways you can adapt CBT with autistic clients?

• keeping it more behavioural and less cognitive

• using more visual aids or readings

• use of emotion thermometers

Any questions for Ailsa?

Im seeing a lot of people refer to Talking Therapies services after self diagnosing with Autism following seeing videos on social media. How should we be approaching these conversations?

• keeping the structure consistent i.e., with appt times and days, same room

• be wary of sensory stimuli within the therapy room / wfh setting

• check if they are particularly sensitive to any stimuli

Helpful adaptions to language:

• very minimal jargon and metaphors / abstract language (only if they use it with their words)

• limit Socratic questioning and emphasise closed Q's

Adapting CBT:

• simplify materials

• explore the possibility of family/friends supporting them throughout the therapeutic process

• explore what adaptions would be helpful (collab)

• use a variety of learning aids (i.e., visual, audio tapes)

• more time spent to plan hmwk and explore barriers

Other learning:

• spend more time exploring psychoed at the start of therapy, ensuring there is mutual understanding i.e., hxb cycle, what emotions look like to them and how they express them

• consider focusing more on behavioural techniques vs cognitive

• each autistic individual is different (as is every other person); spend time at assessment getting to know them as a person

questions:

• how to approach people who have no official diagnosis yet they believe they have neurodivergent traits based on friends/family/social media exposure

-   Allow time for communication processing.

-   Check each other’s understanding.

-   Individual might not be able to give information about thoughts.

-  As a therapist be more directive, ask fewer open questions.

-    Be more visual with sharing information.

-     Don’t force eye contact.

-    Don’t assume easy interaction.

Written communication

-          CBT sheets/ diaries need to be adapted improving quality and structure.

-          MDS measure clarity on scales. E.g. Not all all/ few days

Any other key learning points?

-Psychoeducational approach is helpful for them.

- Developing an individual scale of emotional experience, using example of music based on client special interest can help them relate to psychological concepts. –

Formulation and goal setting/ Active change method

-     More demonstration from the Therapist

-    Ensuring CBT foundation skills are in place.

-  Therapist modelling and demonstration is important.

-    Always consolidate learning.

-   Using Visuals to convey treatment Principles.

-   Supporting new behaviour- eg. Homework, support with planning or help needed.

-  Generalise their learning to outside of treatment.

-   Generate new rules ie. Contamination, helpful to clarify the new rule.

-  Using relapse prevention, making an appointment with that, and keeping a routine is helpful for them.

-  Taking more time at Assessment to understand things better.

• Sensory stimulation- lighting, temperature, noise etc in both in person sessions and online

• Routine and structure of sessions- try to maintain the same room and appointment time

What are some helpful adaptations with your use of language?

• More direct, closed questions rather than open questions

• Develop a shared language for how they describe their difficulties, including the language they use for autism

• Less metaphors

• More visual aids

What are some ways you can adapt CBT with autistic clients?

• Use more visual aids and keep things more concrete

• Help clients to understand emotional literacy more with psychoeducation but also to use their language and develop a shared understanding of what they mean

• Give them time to answer questions

• May go at a slower pace

• More therapist modelling

• More invivo experiments

• Keep it more behavioural

Any other key learning points?

• it might be helpful to spend some time on emotions before jumping into active change methods

• drawing out different levels of emotions and using the clients language is really helpful

• more repetition may be needed

Any questions for Ailsa?

How might you set up experiments and identify predictions in a way that is concrete and easy for the clients to understand and get the most from them?

Considerations could be elements such as background noise, lighting, tactile elements, tempurature (always consider sensory envrionment tailoring it to the individual), consistency

Online - brightness, sounds, business on the screen, colours on the screen

What are some helpful adaptations with your use of language?

Increase the use of closed questions, modify language to fit with the inviduals needs, shared understanding of vocab, avoid metaphors, don't assume fluid conversation

What are some ways you can adapt CBT with autistic clients?

Exploring the use of emotions together (using images, body maps, create more visual learning tools if needed, explore sensory needs with the invidual and how they might learn best, ask for what has helped previously / school?

Any other key learning points?

- Spending time on emotions!

- Behaviour change might take more time, repetitive and graded practice

Any questions for Ailsa?

How to manage patient frustration at not getting something?

^{What are some practical and environmental considerations when working with autistic clients, e.g. where and when you see people?}

• ^{How busy, bright etc is the room}

• ^{Consistent time and place} 

• ^{Control sound, lighting etc as much as possible} 

• ^{Most importantly discuss environmental considerations w/ the patient to get an individualised view of their needs} 
  

^{What are some helpful adaptations with your use of language?}

• ^{Avoid metaphors and idioms} 

• ^{Be clear} 

• ^{Give time for the patient to respond} 

• ^{Socratic dialogue can be unhelpful}

• ^{Don’t assume that expression of language correlates with level of language understanding} 

• ^{Don’t double question} 

^{What are some ways you can adapt CBT with autistic clients?}

• ^{Use images} 

• ^{Don’t force eye contact} 

• ^{Autism is very individualised, so ask about their experience} 

• ^{Create own scale for emotions, use their own language to describe emotional experience} 

• ^{Use special interests to assist in explaining concepts} 
  

^{Question -} 

^{There are many many people on the CBT waiting list who are currently on the ASD assessment waiting list too - as an ASD assessment is often a years-long wait, which is often very distressing, do you have any advice for supporting those patients?} 

-Having consistency around the structure of sessions and appointment times/locations

-Check in with them about environment such as noise/lighting in sessions

What are some helpful adaptations with your use of language?

 -allowing process time for client to respond

-Check in regularly

-more directive and less socratic

-Visual aids where necessary

-less metaphors and forced eye contact

-adapted resources

What are some ways you can adapt CBT with autistic clients?

 -drawing upon clients special interests to convey information/concepts

-map bodily symptoms

-more behavioural, less emphasis on cogs

-Practice in session/modelling to client

Any other key learning points?

 -Can include family/friends for support where necessary

-Spend more time getting to know client at the start, don't make assumptions about person as everyone is different

Any questions for Ailsa?

-i have had a client in the past who had not mentioned their autism diagnosis but i have seen this on their demographic information/GP referral. Is this something we should wait for clients to mention to us or is it okay to gently ask in the session (as a means to find out how to support them?)

Main things

Working with people with the diagnosis of autism:

-        Autism helpful  to work on the behaviour aspect things instead of cognitions.  Smart goals

-        Helpful to include og triggers of the autism.

-        Have to be realistic about what they can do. Do not be strict on their safety behaviour as it is a way of them coping skills. SO just exploring with them what their coping mechanism

-        Including emotional literacy

-        Taking slow

-        Extra time with them – on the difference between the thoughts, emotions and behaviour

-        Be visual

-        Cut the jargon out 

-        Setting up like an agreement at the beginning -eg. How to cope if they get easily frustrated or unsure how to express themselves. What can I do to help them ease that emotional expression or difficulty with expressing? Asking what would be th best way to contact them, Easy read language and documents.

-        Get the meaning of their words – because they might express it differently

-        Question? Behavioural experiments adaptations?

-          How do they prefer to describe their diagnosis?

-          How do they want to be referred to in terms of the diagnosis?

-          How important is the diagnosis in their identity?

-          What are their communication and sensory needs?

This conversation could be facilitated with the use of the “Pre-clinic autism information form”.

2. The importance of developing visual, individualized rating scales and prompts to help the client express their emotional experience. Not only talk things through, but draw them out too! Very creative.

3. Generally speaking, never make assumptions. For example, understand the client’s executive function differences and repetitive behaviours, and based on these, make sure the goals are as specific as possible. Also, understand that clients have very specific routines, so the therapist needs to ensure that homework fits into this routine.

• Keep the same routine/familiarity/structure – time/date, same room/ same layout

• Take into consideration the sensory environment – temperature of the room, lighting, sound and same layout.

Adaptations with use of language in session

• Match language to fit the patient – ask the patient about preferred vocab

• Avoid the use of metaphors or complex language

• Use fewer open questions/socratic dialogue

• More closed question

• More direct language

• More pauses/ make space for patient to process

CBT adaptations

• More sessions

• Discuss adaptations with patient.

• Discuss with patient their learning style – don’t make assumptions – autism is individualised.  

• Use patients own experiences/interests to explain concepts

• More focus on changing behaviours rather than cognitions

• Use more visual aids

• Individualised ratings – numbers, colours, words, visuals

• Practice rating emotions often

• More pauses – to give more time for patient to process questions and give responses

• Don’t force eye contact

Additional resources that can be helpful

• Get patient’s insight of their experience living with autism what is the impact?

• Explore social support systems and possibility of having that support during their therapeutic journey if the patient is open.

Questions

How do you support individuals who have not had a formal diagnosis and/or are on the waiting list for the ASD service.

• Ask if any particular sensory sensitivity.

• Be aware of sensory stimuli in the therapy room (light, sound, temperature).

• Keep same room and time each week.

Language adaptations:

• Avoid metaphors.

• Be clear/direct - avoid being vague.

• Socratic dialogue not always helpful.

Adaptations:

• Create individualised scale for emotions if emotional literacy is an issue.

• Body map for sensations.

• More visual aids.

• Use of special interest to explain concepts.

Other learning:

• Focus more on behavioural rather than cognitive techniques.

• Autism looks different for everyone so explore what it is like for the individual.

Questions:

• How to work with cognitive restructuring in autistic individuals?

Environmental Consideration:

-Ask about sensory challenges e.g. lightning, background noise, etc.

Adaptations:

1. Give extra time if needed to discuss CBT foundation skills early on session.

2. When co-creating formulation, it can be helpful to include trigger autism-specific?

3. Reduce excessive metaphors and open questions.

4. Allow space to reflect and think.

5. For the intervention to be more focus on behavioral change rather than cognition.

Overall learning:

I have learned not always to assume a 'problematic' behavior is a safety behavior it could be a coping skill. Therefore, it would be helpful to reflect on whether it needs to eliminate these behaviors to promote positive change.

Questions:

When doing depression work, how can we adapt treatment to address rules/ assumptions and core beliefs?

·       Environmental considerations include the noise and lighting levels of the therapy waiting room. Even the textures and materials of furniture should be considered.

·       Practically, it is important to give clients time to answer questions and to not ask another question if they are taking longer to respond. This is because we do not want to overload them with information when they may need time to interpret and translate what has already been said. Additionally, ensure there is consistency with the time and date of sessions.

What are some helpful adaptations with your use of language?

·       Avoid using metaphors and hold back on the Socratic questions

·       Use more closed questions

·       Ask the client for their preferences regarding jargon and vocabulary

What are some ways you can adapt CBT with autistic clients?

·       Create idiosyncratic rating scales such as the body map to explore emotions.

·       Use visual aids/materials throughout treatment, make abstract concepts clear and visible.

·       Allow more time in sessions to ensure processing occurs.

·       Be open and direct with them

Any other key learning points?

·       Though there are diagnostic criteria for ASD, everyone experiences it differently so don’t assume each client has the same presentation of this. Tailor your treatment according to what you learn from the client. 

Questions:

How would you adapt CBT for clients presenting with contamination OCD and ASD?