I often talk about the usefulness of cognitive behaviour therapy (CBT) in treating mental disorders, and my optimism is usually warranted. But CBT is not a panacea, and individuals with autism spectrum disorder (ASD) are systematically left out of treatment studies. This means that, for all its usefulness, we know close to nothing about how well CBT works for individuals with ASD. Another consequence is that we leave it up to each individual therapist to adapt therapy, which is challenging.

Other mental disorders are common in ASD

Individuals with ASD often experience co-occuring mental disorders, but we don’t know how to treat them effectively. I don’t think the solution is to include individuals with ASD in all treatment studies, because standard CBT is less effective for individuals with ASD. Still, estimates of co-occuring mental disorders are high: 37% of individuals with ASD also have depression, 26% have generalised anxiety disorder, and over 20% have obsessive-compulsive disorder. We need adapted treatments that take the difficulties related to ASD into account.

Autistic individuals struggle with social cognition

Autism spectrum disorder is characterised by difficulties in social communication, as well as restricted interests and repetitive behaviour. When researchers compare the cognitive functioning in adults with ASD to neurotypical adults, they find that adults with ASD show impairments in social cognition. Social cognition includes theory of mind–knowing that another individual can have other desires and beliefs than yourself–and emotion perception and processing (understanding emotional expressions in others). These difficulties make psychological therapy challenging for individuals with ASD.

Attending a therapy session involves meeting a new person, speaking with them about personal information, and building up a rapport over time, all processes which can be challenging for the autistic individual. - Cooper K, Loades ME, Russell A. Adapting psychological therapies for autism

Adapted CBT for ASD

Despite commonly co-occuring, few studies have evaluated adapted CBT for individuals with both ASD and a mood or anxiety disorder. A recent overview that included 11 studies found a medium effect size (g = 0.52) in favour of CBT versus control conditions. Most of the available literature to date is from small studies and, previously, only two studies have looked at adapted CBT for adults with ASD and OCD. In our clinical effectiveness study for adults with ASD and OCD, there were large reductions in obsessive compulsive symptoms but non-significant improvements in general functioning and quality of life. The small amount of available evidence suggests that there is room for improvement in the adapted treatments, particularly if we want the treatments to lead to sustainable gains in general functioning or quality of life.

Some practitioners recommend useful strategies that they have used to adapt CBT for individuals with ASD. However, these adaptations have not been systematically evaluated and the authors stress that therapists should use their clinical judgment in applying these adaptations.

Adaptations to CBT
Longer sessions
Taking breaks
Using a more directive approach
Avoiding metaphors and abstract concepts
Using images and written material
Adapting information to fit with the individual’s special interests
Practice in recognising, labelling, and rating the intensity of emotions
Involving family members and other support


Can we assume that CBT is an effective treatment for adults with ASD, because it has been found to be effective for individuals without ASD? The available evidence to date suggests that the answer is a resounding no. That’s why we need more research into which therapies work, and which don’t, for adults with ASD.