Cognitive Behavioural Therapy (CBT) is a well known, well used form of therapy for many people of all ages across the whole of neurodiversity (that’s all people). It is well respected and used heavily within and beyond the NHS, as a short-term talking therapy.

Essentially, CBT aims align our thoughts, feelings and behaviours to prevent any or all of these from having a negative impact on our mental health and in our ability to function effectively in our day-to-day lives.

 

WHY USE CBT?

Charlie has been referred for CBT because they are depressed and have been signed off sick for some time by their GP. Through weeks of discussion with Charlie, the therapist eventually establishes that the prospect of going to their regular job gives them such extreme anxiety it produces debilitating physical and mental health symptoms – panic attacks, migraines and depression, to name just a few. This has led to them becoming increasingly socially isolated as they’ve now lost their confidence and motivation in all areas of their life, as a consequence. It takes a number of sessions before Charlie feels able to share that they feel ‘like a square peg in a round hole’ at work. They are adamant that, however hard they have tried, they just don’t fit in, in an otherwise close-knit team that socialises together frequently, and seems to delight in contributing to their team WhatsApp group in the evenings and at weekends. The pressure to be part of this team and to be ‘one of the gang’ is now too much for Charlie to cope with, after months of trying to make it work. They are exhausted and can’t imagine ever being able to return to the role that they loved. They wonder how they ever held down the job in the first place, or why they were even hired. The dread that greets them every day when they wake up makes them feel ill and the thought of trying to function makes them freeze. They know that their excuses for calling in sick have not been convincing, but they haven’t been able to be truthful about how difficult they find the work environment: the constant banter, the noise, the pace, the goal-setting, the birthday cakes and knowing what to write in cards for people they don’t know, the laughter, the practical jokes, the after work drinking and sports, the Christmas party. Basically, everything about that job except for the actual job that Charlie was employed to do, and is very good at. To Charlie, the fact they’re good at their job seems to be less important to their employer and colleagues than the social aspects. They’ve never felt more like an outsider and Charlie is experiencing feelings of hopelessness. Charlie’s GP feels that CBT will really help them overcome their feelings of social rejection and anxiety with the aim of Charlie returning to their job with a different perspective.

 

CBT theory would state that Charlie…

THINKS that they are not good enough, that something is wrong with them, because they don’t fit in with their work environment, or the associated social life. They think that they will lose their job and then they will lose their home if they don’t fix this problem about themselves. They also worry that they are losing their friends from outside of work because they’ve become so reclusive in recent months, as a consequence of their work-related depression.

FEELS desperately anxious and depressed. They feel like a failure because everyone else around them is having a great time and thriving on such a friendly work environment. So, Charlie feels that they must be the problem here. They feel that there is no solution other than seeking therapy that will identify the problematic thoughts and feelings that Charlie has, and change them. Charlie does have a few really good, long-term friends outside of work, but feels unable to reach out to them for advice because they are embarrassed and ashamed.

BEHAVES in ways that are frightening to them. They struggle to even get out of bed and get dressed most days. They ignore phone calls from family and friends. Their diet has grown poor and they have lost interest in all of the activities that they used to enjoy. Charlie is so afraid of losing their job and home that this is all they can think about. Charlie becomes more and more withdrawn and isolated and the only way they can control the escalating levels of anxiety is to stay at home, in familiar territory and just shut it all out. Charlie is now physically and mentally unwell and every day is dominated by their fear of losing everything. They have taken to ignoring their employer’s calls and have not read or responded to any of their emails because the very thought causes them too much anxiety, and Charlie has no answers. Their behaviour has changed so much since they got this ‘job of a lifetime’ that their relatives and close friends are very worried about them – they are barely recognisable as the same person. Charlie knows that they are not coping and their lack of confidence means they’re about as far from being able to apply for more suitable jobs as they could possibly be. They are in deadlock.

 

CBT treatment would aim to help Charlie…

find ways for them to gradually remove the fear of social interaction, by taking small steps to overcome the dread that has seemingly got out of all proportion. The therapist would expect Charlie to do A LOT of homework, using the tools that they are showing them. Little by little, Charlie would ideally find that that across the desk banter at 8.30am is actually tolerable, even enjoyable, once they relax and roll with it. They would find that their colleagues are good fun, friendly even. Ultimately, Charlie may even join the after work activities. Charlie’s behaviour changes radically over the course of time. They don’t think about getting up and going to work any more – they just do it. In fact, they’re enjoying the sense of routine and having a useful role in the world. They’re still really good at their job and now it’s likely they will be promoted as well, as they’ve shown they are a ‘team player’. Charlie knows that their job and home are safe.

 

Hang on… Did I mention that Charlie is autistic?

Now you have that information, re-read the paragraph WHY USE CBT? If I also add that this is their first job since leaving university, hence they have no point of comparison with other work environments. To them, this is what work IS. Charlie believes they are being unreasonable in not being able to fit in. They think they are faulty and that with enough CBT they can learn the social skills required. They may be able to but, if Charlie has sensory hypersensitivity, may even be an undiagnosed dyspraxic and find the prospect of team sports intolerable based on their performances at school. They may have always struggled with neurotypical work banter and the pointlessness of it, as Charlie sees it. They applied for this job because they absolutely love the work, it ties in perfectly with their special interest, and, any other demand, Charlie sees as a distraction that will reduce their output and their satisfaction. Their attempts at masking, when they first joined the firm, cost them so much energy, that they haven’t been able to maintain the facade. Going off to walk in the park alone at lunchtimes gives them a much needed break from the sensory overload, but they are now viewed as unfriendly and strange. Charlie’s teammates ignore them or make sarcastic comments to each other about them. Their employer, watching this poor interaction between Charlie and the team, genuinely does feel that, sadly, they are not the promotion material that they had hoped, which frustrates the boss because Charlie is the best they could have wished for on paper.

 

What if it isn’t Charlie’s cognition and behaviour that’s the problem?

Does Charlie, following the CBT process, need to change their thinking? Do they need to change how they feel about social pressures to conform? Do they need to change their behaviour from someone who is quietly and diligently doing their work? NOT AT ALL! Charlie is NOT the problem here – their environment is the problem. So, putting the onus on Charlie alone to change, to adapt to be more like their neurotypical colleagues, their employer’s emphasis on how vital socialising is to career development, is only going to make them more depressed, more anxious and more ill. Charlie is being asked to camouflage their true identity for 8 hours a day (plus social activities), every day of their working life. That isn’t sustainable. In all likelihood they will still lose their job, and potentially their home. CBT, for Charlie, has solved nothing. Worse than that, Charlie has left their brief course of CBT (because they ARE usually very short-term) feeling even more of a failure, even more hopeless. Charlie is unlikely to seek other forms of support at this stage because they feel that they are beyond help.

 

What if there was another way?

If Charlie’s identity as an autistic person was respected, their employer could give them a quieter working environment. They could ask Charlie to write a list of what they need in order to be happy in the workplace (remember, it is the law in the UK for an employer to make ‘reasonable adjustments’ for autistic people. They could educate the other employees about autism. They could take all of the pressure off Charlie to attend social functions – who cares about all that nonsense if Charlie is doing the job they were hired to do, and doing it magnificently? They could suggest that Charlie start a chess club at work, or a board games group, or gaming, or poetry, or to set up a lending library, or anything non-sporty that taps into Charlie’s actual interests. Maybe Charlie could just be left to enjoy their daily walk in the park at lunchtime each day, without feeling like they have to undergo some kind of fraternity initiation. There are many neurotypical people who hate team sports, after all! And the chances are that there would be other neurodivergent people in that very workplace, who would appreciate that this is something that is finally being talked about. Charlie’s very particular and advanced skills in their work role can be highlighted to the other staff as a positive thing. It is, after all, their hyperfocus and attention to deal that made them the ideal candidate for the job. Charlie could relax a little, knowing they were accepted and respected for who they are. No change necessary.

Idealistic? Well, only from the perspective that it’s not easy to change ingrained attitudes and expectations. Charlie was always good at their job. The problem was only ever their environment.

Despite wide recognition of CBT’s limitations for the autistic population, it continues to be widely used by clinicians across the world in order to ‘adapt’ the behaviours of autistic people, particularly for children with social anxiety and behavioural ‘problems’ (such as meltdowns). There is, thankfully, more and more research that demonstrates that, not only is CBT ineffective for many autistic people, but that it is often detrimental, as autistic people are being ‘trained’ to be someone they can never be – a neurotypical. Notably, autistic children rate the effectiveness of their CBT as being much less so than their clinicians do, and even their parents – click here for just one example. Most CBT courses, particularly within the NHS, are limited to the typical six-weeks-and-you’re-out. Considering it could take most, if not all, of those sessions for an autistic person to even trust and develop any sort of relationship with that therapist, they may not have even reached the stage of being able to talk about their deep seated fears and anxieties after such a short period. Not to mention the inappropriateness of the dreaded homework that we have to then implement without many of the neurotypical skills that would make this feasible.

The overarching problem with CBT, in my view, is that it’s aim is to

1) make the individual take responsibility for why they think, feel and behave as they do, as if that is the core of the problem and

2) make that individual adapt to fit into a world that isn’t created for us, instead of addressing the societal problems that leave us so physically and mentally ill and feeling like we’re lacking. The solution is CBT (Complete Bloody Transformation) of societal expectations. Now that is surely the best therapy there can be for us who sit on the fringes?

That’s not to rule out all forms of therapy, not at all. Here is just one clinical psychologist’s take on how and why neurotypical therapy should be adapted for autistic people.