Jassi Amita - OCD and autism: a clinicians guide to adapting CBT

OCD AND AUTISM

A CLINICIANS GUIDE TO ADAPTING
CBT

Ailsa Russell, Amita Jassi
and Kate Johnston

Illustrations by David Russell

Jessica Kingsley Publishers
London and Philadelphia

CONTENTS

ABOUT THIS BOOK

Who is this book for?

This clinical workbook is written with the cognitive behavioural therapist in mind. We assume that you have knowledge and experience of helping people overcome obsessive compulsive disorder (OCD) using behaviour therapy and cognitive techniques. We do not assume that you have prior experience of working with people with autism. The aim of this workbook is to guide you in adapting your knowledge and skills so you can help someone with both OCD and autism. The workbook may also help you in your work with people who do not have an established clinical diagnosis of autism but who identify with aspects of the clinical presentation. This book will not serve you alone and you will need to learn about a persons autism so that you can individualise some of our suggestions. Patience and creativity will also be important. We link practice to theory at points we think it will be helpful, but this is very much intended to be a practical clinical workbook. We have included supporting references and suggestions for wider reading.

Why this book?

This book is based on a manual developed for a randomised controlled trial (RCT) investigating the usefulness of adapted cognitive behaviour therapy (CBT) for autism spectrum disorders (ASD) (Russell et al. 2013). Young people and adults over the age of 14 with a diagnosis of autism spectrum disorder and intellectual function in the average range who had a co-occurring diagnosis of obsessive compulsive disorder (OCD) took part in the RCT. The RCT manual was not developed for younger children or those with a significant intellectual disability who may require additional adaptations. Participants in the RCT were randomised to either adapted CBT for OCD, or anxiety management (AM). AM comprised up to 20 individual sessions with an autism experienced clinician, and participants learned about anxiety, progressive muscle relaxation and healthy habits. There was a significant effect of treatment in both groups, which means that both treatments were beneficial. One treatment was not superior to the other but there was a trend towards more of the people who had adapted CBT doing better. As well as telling us something about the RCT, it is important to note that anxiety education and anxiety management may be helpful for some people with autism and co-occurring OCD, particularly if the OCD symptoms are in the mildly severe range.

How does this book work?

This book aims to supplement evidence-based protocols and texts (e.g., Kyrios 2003; Wilhelm and Steketee 2006; March and Mulle 1998) outlining cognitive behavioural interventions for OCD. This book describes autism-specific adaptations to the standard CBT approach to OCD as outlined in these and other texts.

To get the most out of this book, we suggest that you read the first few chapters: Introduction to Autism and Adaptations to Cognitive Behaviour Therapy, Assessment of OCD in Autism and CBT Phase 1: Building Blocks for Treatment as a starting point for your intervention. The other chapters highlight a range of adaptations to standard CBT that may be useful in adapting your usual clinical practice. You may not need to make use of all the modifications with a single client. You do not need to follow the suggested order of adaptations and clinical tasks in this book.

A key theme in the adaptations is the use of visual material. We have been able to use a limited number of images in this book, and are restricted to monochrome. In clinical practice, we would suggest using colour images to make materials as engaging as possible.

Talking about pictures, we have relied on family to create some unique images for us. We are not great artists and if the person we are working with is not keen to draw, we all resort to online images, photographs and other media.

We are using two case vignettes, Harold and Tanisha, to illustrate the adaptations to practice throughout. Although both fictional, they are based on our experiences of working with this client group and we will introduce them here.

Harold

Harold is a 22-year-old man who received a diagnosis of autism when he was aged 15. Harold lives at home with his parents. He has several younger siblings. Harold left school after GCSE level. He was bullied by his peers and did not want to go to sixth-form college. He spent several years at home, not engaged in education or employment. He spent his time playing computer games and fixing up his motorbike. Harold has always been interested in motorbikes and has many magazines, pictures and mechanical projects related to this. Harold has always struggled with anxiety, tending to avoid situations which make him feel uncomfortable. On transition to secondary school, he had counting and checking rituals for several months. Support from the local child psychology service was helpful with this. More recently, Harold has expressed fears about contamination, particularly coming into contact with germs which might spread illness. This has affected family life considerably, with Harold refusing to use communal dishes and cutlery, eat food prepared by others or sit close to family members. Harold has been offered a place on a motor mechanics course at a local college. He would like to attend and qualify as a mechanic. He would like help in overcoming OCD as he does not think he can attend college because of this.

Tanisha

Tanisha is a 15-year-old girl who received her diagnosis of autism when she was 7 years old. She lives with her mother and grandparents. She is an only child. Tanisha stopped attending school one year ago due to the severity of her OCD. Her symptoms started when she transitioned to secondary school but worsened following an incident where she was told off by the school bully in front of the class. Her OCD fear is that she may turn into her school bully (transformation obsessions) and she has a fear of transporting into an alternative parallel universe. Initially, Tanisha avoided items related to school that may have come into contact with her school bully, would remove her uniform at the front door and would not bring any items from school to home. Eventually she stopped attending school completely due to her OCD. While at home she continued to engage in compulsions, including repeating rituals where she would continue to walk back and forwards over thresholds due to fears of transporting to an alternative dimension. She would engage in a range of checking rituals to make sure she had not changed into her school bully but also to check that she was not in an alternative universe, for example tapping objects, and asking family for reassurance that she was still in this universe. Tanisha has special interests in animals, particularly horses, and wants to be a vet when she grows up. She was academically doing well in school prior to the onset of her OCD and was hoping to study A-levels in order to become a vet in the future.

The handouts and worksheets are available to download
at www.jkp.com/voucher using the code KYEWAZO

Chapter 1

INTRODUCTION TO AUTISM AND
ADAPTATIONS TO COGNITIVE
BEHAVIOUR THERAPY

Agenda

Introduction to autism

What to call autism spectrum disorder?

Adapting talking therapies for people with autism

CBT-specific adaptations

Introduction to autism

Autism spectrum disorder (ASD) is the diagnostic label given to a neurodevelopmental condition characterised by qualitative impairments in social communication and a pattern of restricted or repetitive behaviours, interests and activities. ASD can affect people across the full range of general intellectual function. In approximately 50 per cent of people, a diagnosis of ASD is associated with intellectual disability.