CM402 - Anxiety & Depression

Presenter: The thing that I’m going to attempt to accomplish today is to talk to you and give you a

little overview of anxiety and depression, which is one of my favorite things to talk

about in sort of in my work. I started getting into it a number of years ago when it was

a new thing to be studying. And I’m very excited to be able to present what I can

present to you now because we’ve learned quite a bit in the last seven or eight years.

I’m going to spend the first half of our talk today talking about why we should care

about anxiety and depression in individuals with autism spectrum disorders, which is

probably something that most of you, since you’re all here, already understand why it

is important that we care about these things. But how we identify the symptoms,

which is a very challenging task in this population, and then understanding the

disorder. And then for the second half of our presentation today, I’m going to try and

give you an overview of what best practice treatment looks like at this time.

So when I first started giving this presentation and got interested in anxiety and

depression in individuals with ASD, this question really I had to answer every time I

gave this talk because it – people didn’t understand, and I felt like the population of

treatment providers, a lot of them didn’t understand why they really did need to care

about anxiety and depression in ASD.

But now we’ve come a long way, and for the – most of the time, I don’t have to

answer this question. But I’m going to answer it anyway because I like to give people

a little bit of ammo they’re taking back to wherever they are working with sort of why

we really need to be spending a lot of time talking about anxiety and depression and

other mental health conditions in individuals with ASD.

The first reason is probably the one that we have probably heard about the most, and

that’s the prevalence and that, although we don’t have great numbers on prevalence,

we do know a few things on it. The first thing that we know is that they are –

symptoms of anxiety and depression are very, very common in individuals on the

autism spectrum. In the general population, and all of us for the most part, you would

estimate that lifetime prevalence of having a psychiatric disorder would be

somewhere between 10% to 25%.

In ASD, the estimate is significantly higher, and although we don’t have a really great

number, the estimate is probably somewhere between 40% and 80%, and that is of

those who develop the – a condition significant enough that it could be qualified as a

disorder. There are lots of other individuals who have other symptoms who wouldn’t

necessarily get diagnosed with a disorder. But that is a pretty sort of discrepant

statistic from what is prevalent in the general population.

In addition, we know that for some reason, and we’re not – well, we hypothesize, but

we’re not sure exactly why, but individuals with ASD are more likely to have an

anxiety or a mood disorder or other type of psychiatric disorder than individuals with

other kinds of developmental conditions, such as Down syndrome, intellectual

disability. And there’s – we’re not sure exactly why that is, but at this point, these are

sort of our best hypothesis and that ASD is considered a risk factor for mental health

problems because it is an organic, neurobiological disorder with numerous associated

medical conditions.

So what we know about autism is that it is a brain-based disorder and that some of

the areas that are impacted in the brain are some of the same areas that are

impacted in numerous other psychiatric disorders, likely making individuals a little bit

more likely to develop those conditions.

The core deficits of ASD impede the development of certain strategies for coping with

strong emotion. Throughout our lifetime, from when we are very young to sort of

growing up, we spend a lot of time developing coping strategies, but if you have

certain types of difficulties in executive functioning, in emotional regulation, in

generativity, in problem solving, which are some of the things that you – we see in

individuals on the autism spectrum, you have a lot more difficult time learning how to

cope with strong emotions.

So compared to some other types of conditions for whom you don’t have as much

difficulty with, say, generativity where generativity, the idea that – which we need for

problem solving. So if we have how you solve a problem – and if anyone’s taught

problem-solving to individuals, there’s usually this little process that you go through.

You identify your problem. You come up with all the different possible solutions. You

select your solution based upon different types of perceived outcomes, implement

your solution, and see whether or not it worked, but – and we all do this like that

without even really thinking about it.

But for some of our individuals, we have to teach this, and the part that is often the

most difficult is the coming up with numerous solutions to a problem. So what we see

a lot in individuals on the autism spectrum is that they have learned one way to cope

with a problem, but don’t know how to adapt and don’t know how to generate other

solutions to that. So in this way, certain types of neuropsychiatric characteristics

associated with an autism spectrum disorder lead certain individuals into being more

at risk for difficulty learning how to cope with anxiety and negative mood.

And then we know that individuals with ASD encounter greater stress in their life.

They have more negative life events. Their families have more negative life events.

There are sort of greater stressors financially, less social support, and all these things

place individuals at a greater risk for psychiatric disorders.

The other reason I think we should care about it quite a bit is that it has a huge impact

on an individual’s life and sometimes becomes something that is as interfering as the

– as what some people think of as the primary disorder of autism. And sometimes it is

even more significantly impairing, the psychiatric disorder, than the autism spectrum

disorder. It can interfere across numerous different environments.

It can really exacerbate the core symptoms of a developmental disability. It can

prevent you from accessing the right kinds of environments to be able to work on

things such as social skills, to be able to work on things such as communication, if

you are not able to get out into those areas. And if you are – and a heightened sort of

emotional state throughout much of your day because you’re dealing and coping and

dedicating so much of your time and resources to managing emotion, I think you have

a little bit harder time acquiring the skills that you need to address some of the core

deficits.

The last thing that I like to mention is that untreated anxiety is associated with later

depression and that these conditions don’t really get better over time. So there’s kind

of a myth that anxious little kids, both typically developing and those who have an

autism spectrum disorder, will grow out of it, you know, at some point in time. And

what we know about anxiety and depression is that you don’t really grow out of it.

There is sort of a spontaneous remission rate that is pretty low, 8% or 9%. So that’s

not a pretty impressive statistic compared to the number – the, you know, the 90%

who persist with having an anxiety disorder, which can lead to later depression. And

we’ll talk about why anxiety leads to later depression in a little bit.

Now the last thing that I love to talk about, and the reason you’re probably all here, is

that we’ve learned actually quite a bit in the last six or seven years about how to treat

anxiety and depression. There’s some really great studies that have come out and –

since about 2009 to 2012 indicating primarily that treatment associated – behavioral

treatments and cognitive behavioral treatments can have a very, very significant

impact on anxiety and depressive symptoms, which is really, really exciting. So

sometimes it’s hard to talk about anxiety and depression. We don’t really know what

to do about it. But we actually have some useful tools, and we actually have some

ideas about what to do, which is pretty exciting.

There’s – some of these studies have some pretty impressive data, which is – I’m little

bit of a data geek, so – and that it’s fun to talk about that a little bit. The Wood et al

study 2009, which I also like to talk about because I worked on it, was a study in

which they found an 80% reduction rate in – a clinically sort of significant reduction in

symptoms after what is only 14 to 16 individual sessions of treatment, which is pretty

remarkable. For those of you who work with this population, if you get 80% of a

treatment response after sort of 12 to, you know, 16 sessions of treatment, that’s

pretty amazing. So but it’s a – we have a lot of reason to be hopeful that we can really

address this problem.

Why haven’t we addressed this earlier? I think that we have – there’s been a general

sort of myth that individuals with developmental disabilities or autism spectrum

disorders are a little bit immune to things such as anxiety or depression or they don’t

experience the same types of range of emotion, which is a little bit ridiculous actually.

And that I think the hardest – I think the biggest thing also is that they’re really hard to

tease out and so – because so many of the things associated with an autism

spectrum disorder can sort of overshadow or mask symptoms of depression or

anxiety.

And so it can be really hard to diagnose, and if we’re not really good at things, we

don’t like to do them. And I think because we weren’t very good at diagnosing it – I

still don’t think we’re great at that, but we’re getting better, and we’re getting better at

treating it, I think we’re more likely to hear about it in the future.

So I’m going to talk a little bit about identifying the symptoms. Now we all know about

the symptoms of anxiety because we all experience anxiety. If you don’t, I’m very

envious of you because I experience anxiety. In fact, I’m experiencing quite a bit of it

right now. I am a notoriously socially anxious person, and it is an unfortunate problem

with my job that it is part of my job that I have to engage in public speaking. And so

during – and I – well, I’ll talk about this a little bit later about how I got over it to some

degree or how I manage it, I might say, is – but we all have things such as this that

help sort of induce anxiety in us.

Some of the symptoms that we’re probably all familiar with: restlessness, irritability,

fatigue, somatic complaints, difficulty with concentration, sleep problems – I didn’t

sleep very well last night – physiological overreactivity, a little bit of a startle sort of

response, shyness, fearful responses to stimuli, difficulty separating from others,

chronic worry, distressing thoughts, avoidance, repetitious behavior, nightmares,

those types of things. We’re familiar with those things to some degree, and we’re

supposed to have some level of anxiety in our life. It’s quite adaptive. So you know

what those things are.

And symptoms of depression, we also sort of know what this is. It’s common to have

periods of low mood. Life is not always a joy. Symptoms of depression are low mood;

irritability; restlessness; loss of interest in things; wanting to just hang out on the

couch and eat potato chips and watch HDTV, which is what happens when I get

depressed; over or under eating; aches and pains; withdrawing from things; not

wanting to go out; guilt about whatever report I haven’t finished; worthlessness;

decreased motivation; hopelessness; sleep difficulties; low self-esteem; loneliness;

thoughts of hurting oneself; poor concentration; difficulty with decision-making; and

poor hygiene.

And so the other thing that I want to point out with these lists is if you look at this one

and the previous list, there’s quite a few that are commonly associated with an autism

spectrum disorder, even not in the presence of an additional psychiatric disorder:

irritability, somatic complaints, difficulty with concentration, sleep problems, repetitious

behavior, difficulty separating from others, over or under eating, withdraw, poor

concentration, poor hygiene, difficult with decision-making.

And these lists of symptoms right here are the lists of symptoms that our – the

wonderful creators of the Diagnostic and Statistical Manual of Mental Disorders,

which has a lot of problems, but they – which – and I’m not going to talk about DSM-

5. But that there are – there’s a lot of problems, and they don’t just exist within the

category of autism spectrum disorders. It’s not just limited to that sort of category.

We’ve heard a lot about that.

But these disorders, symptoms of anxiety and depression and the way they are

defined in the DSM at the present time, are defined for individuals who are typically

developing adults. And that is a very significantly different population at times in terms

of – from children and from individuals across the spectrum, sort of the entire lifespan

spectrum with an autism spectrum disorder. And so they are written for a population

that’s very different from our population, and so we’re applying them to a group of

people where we really need different distinguishing characteristics, and we haven’t

really come up with those yet. But I think people are working on it.

And so what do we do about this? I – personally I can tell you what I do about it. I’m

fortunate that I work in an environment where I am not very tied to medical sort of

reimbursement, and I – which is a very fortunate sort of turn of events for me and

which is why I probably will always stay associated with a university, because of that

benefit. But for a lot of people out in the rest of the community, they don’t get quite as

much time or quite as much of an opportunity to do some of the things that I do.

And making a diagnosis of psychiatric disorders is actually really, really hard in the

presence of an autism spectrum disorder. I shouldn’t say always, but, I mean,

sometimes it’s pretty clear, and at other points in time, it can be very significantly

difficult and take a long period of time to sort of come to sort of that decision. And it is

very hard to do in an office visit. So for most people who would potentially be giving

these kinds of diagnoses, a psychologist or a psychiatrist or a developmental-

behavioral pediatrician or some of those people often work in a nice, little office

someplace where somebody comes. And so the diagnoses have to be made largely

upon report, and that’s not always the best way.

Individuals with an autism spectrum disorder are often not great reporters. They have

difficulty to some degree about self-awareness, and they’re not always – in some

cases, they are great reporters, but in other cases they are not great reporters about

their own internal experience and usually will just say – like, if I know someone is

really, really anxious about something and doesn’t want to do it because they’re

experiencing sort of very, very significant anxiety, they might just say – and have

meltdowns associated with it, they might just say that they’re mad. They might just

say that they’re irritated at their mom or whatever it is, but they may not report anxiety

as well.

And so we’ve developed a lot of – in my clinic, we’ve developed a lot of procedures

for working with a lot of people who spend a significant more time with the individual

tracking them over time to get more of an idea of baseline and when the onset of a

psychiatric disorder probably was. But it’s a more challenging process, and I tend to

be personally very cautious and would urge a lot of other people who potentially make

diagnoses in a short amount of time to be cautious as well.

So the last thing to remember is something that somebody that I admire very much

once said – Phil Kendall who works at Temple is one of the sort of the leading sort of

child psychologists in our country at the present time said is, “The ‘book of problems’

really has a lot of problems,” and you can – I urge people not to get really bogged

down in it.

I’m a behavior analyst first sort of deep in my sort of soul, and so the diagnosis is sort

of a means to get access to treatment. But beyond that, you can work with the

behavior, and you don’t necessarily need to have a diagnosis to work with a behavior

that’s associated with anxiety or work with a behavior that’s associated with a mood

disorder. Okay.

So the next piece that I want to talk about is sort of really understanding the disorders.

And you – I talk about anxiety and depression together because they have some

similarities and because they are sort of, in the world, considered the internalizing

disorders. And the internalizing disorders are disorders that are characterized by

really internal distress. So when you sort of know you’re anxious, you feel it. And

when you know you’re sort of depressed, you feel it. And some of the way that we

diagnose these things is based on internal experience. And so we call those the

internalizing disorders.

And contrast those with the externalizing disorders, such as conduct disorder,

oppositional/defiant disorder, ADHD, which are really the disorders where we see

external, too much behavior, that we’re trying to reduce. And anxiety is a behavior –

anxiety and depression are disorders that are characterized by often not enough

behavior. And so we’re going to talk about that a little bit.

They cooccur a lot. Anxiety tends to proceed depression. And an individual who is

anxious avoids quite a bit, and when you avoid, you wind up – you avoid certain

environments in your life, and you wind up contacting less reinforcement. And less

reinforcement in your life often leads to low mood, which sort of cycles into a period of

time where you would experience sort of low thoughts about one’s self and lead into

depression. That’s a slightly simplified version of that, but it – the anxiety does

typically proceed depression, and they have some overlapping characteristics.

So what contributes to them? And you may know some of these things. Genetics and

temperament. There’s a lot of studies in the – out there about both in – mostly in the

sort of typically developing population, that anxiety and depression run in families and

that individuals who have a certain sort of temperament by age, you know, two or so

are likely to carry that same sort of temperament sort of throughout their life.

Certain stressors. Individuals – and we know individuals on the autism spectrum have

greater – experience more significant life stressors than other individuals. A lack of

social support contributes to anxiety and depression in both sort of the typically

developing population and in individuals with ASD.

Extreme thinking patterns. I think this is a pretty – is a problem that I deal with quite a

bit with individuals who have an autism spectrum disorder who tend to think in ways

that are very black or white and are very sort of extreme such as this happened and

this completely ruined my entire life. And if you believe that, then you feel really bad.

And if I don’t get every single thing absolutely right, then basically it didn’t have any

value whatsoever. And those types of really extreme thinking patterns that are very

black or white and very concrete are sort of characteristics that we see in a lot of

individuals on the autism spectrum.

Certain types of behavioral patterns, certain types of behavioral patterns. Someone

might get stuck in (indiscernible) anxiety and depression such as not – such as

avoidance can sort of maintain anxiety. Poor coping, poor problem-solving skills. We

talked about that a little bit that if you don’t learn good emotional regulation skills

because you have sort of interfering deficits related to that, you’re more likely to be at

risk.

And the last section, and sometimes I get in trouble for talking about this, is modeling

and caregiver reactions. So one of the things that you might have – you might know, if

anyone’s taking a social psychology class, you might know that we – a lot of our

anxieties are learned and are sort of modeled by us, and we learn this. And so it’s a

very classic social psychology study that I love to talk about, even if – I don’t know if

everyone finds it a useful part of this talk, but there’s about little infants who are

learning to sort of walk.

There’s a very, very classic study in which individuals who are sort of in the crawling

stage are put on this sort of – I don’t know what you’d call it – platform and where

there is some period – some part that is where you look down. You see the ground.

And then there’s a section of it that there’s a clear plastic thing that you can potentially

crawl over, but when you look down, it looks like you might fall.

So very, very young infants will just crawl right over it. And somewhere sort of around

the age of 10 to 12 months, as they start to stand and start to move around and other

things, they stop, and they won’t cross it anymore. And if you – and then if they – the

same sort of researchers did various studies where they looked at sort of responses

of parents and showed that the fear of heights, of falling down, is actually not in a sort

of present. So if you have a fear of heights, then – and you are very convinced that

you had it since birth, it’s not very likely actually. I have a fear of heights, and it

probably was my mother.

But because parents, when they are – when they see their kids starting to toddle,

well, what do you do? They hover a little bit, and it’s sort of natural. It’s not a bad thing

that they won’t cross over there. That’s probably a good thing. It’s adaptive. And our

bodies are actually – and it’s sort of ingrained in us that we learn anxiety from our

family in this way and that we learn – I learned to not go over on the edge of

something from my mother who is a very anxious, loving, sweet woman, but was

anxious. And so I probably picked up a few things as a result of her. She and I have

discussed this. It’s okay that I talk about it. And we have – and we’re trying not to

pass it on to later people in our family, but we’re not working out – it’s not working out

really well, but –

And it’s – so anxiety, a lot of our anxieties are learned, and the same sort of coping

strategies for dealing with a lot of things are also learned. And parents and individuals

with any sort of – who are raising a child who’s potentially more difficult than another

child are potentially – have this tendency towards even greater sort of excessive

protection is what I call it. And I feel like it’s okay for me to say that a little bit because

I grew up in a family where I have a brother with certain disabilities, and so I’m – I feel

like I’m talking about my own and –

But a lot of parents who are really, really good parents out there are – have a

tendency towards being a little bit too protective. And there’s some – some of this is

good. You have – if you’re raising a child or an adult or whoever with an autism

spectrum disorder, there are greater risks for things. There are – they’re vulnerable

out sort of in the community, and there’s a tendency towards, if you’re going to err on

one way or the other, in pushing them out too far in the world or protecting them a

little too much, the good parents protect a little bit too much.

Unfortunately, what this can do is teach individuals that they are not able to handle

certain situations. And unfortunately, that can contribute, and we have had data on it.

And I know from personal experience that you can learn that a little bit.

So all right. So we talked a little bit about what is – what are the things that contribute

to developing an anxiety or a sort of depressive disorder. But, you know, it doesn’t

really help us very much. You can’t go back necessarily and change what your

mother or father did when you were 18 months old. You can’t really change your

genetics at this point in time. We don’t know how to do that yet. And there’s – you

can’t really sort of come up with some way to reduce stressors.

So the behavioral therapists, cognitive behavioral therapists, don’t really care that

much. And while it’s interesting to talk about, the thing we spend the most time talking

about when we are talking about anxiety and depression but are what maintains these

disorders at the present time. And that’s what we can do something about. And so

that’s what I’m going to talk about for a little bit.

So there are three – in anxiety – I want to talk about anxiety first. Then I’ll talk about

depression. In anxiety, there are three factors that we think about that contribute to

the maintenance of the disorder. And the first is physiological symptoms. So anxiety –

some of us are more anxious than others, and anxiety, if you – when you have it, is

horribly, horribly painful, and it’s supposed to be. You’re supposed to run away from

the snake. You’re supposed to run away from the edge of the cliff. You’re supposed

to, when you get anxious, experience something that is so painful and that is so

uncomfortable to live with that you are going to do something to make it go away, do

almost anything to make it go away.

And that’s, I think, one of the most important things to remember about anxiety and

why anxiety is – can be so difficult to treat is that anxiety and the physiological

experience of anxiety is very, very painful. And we are wired for it to be painful, and

we are wired for it to make us do certain things.

The next sort of factor that is problematic in anxiety is an overestimation of

dangerousness and an underestimation of ability to cope. So I’m going to use an

example of a young woman who I have been working with for about 2 1/2 years, and

she is 29. She has a diagnosis of ASD and numerous other conditions: a bipolar II

diagnosis, generalized anxiety, social anxiety. And she had some specific phobias

when I first started working with her. She has – she’s one of my favorite examples.

She is because she has some really interesting sort of cognitions that clarify for – in a

way, how cognition can really sort of impact.

She is – she – well, her first – the primary reason that I started seeing with her was

that her family had been – for the last eight years, hadn’t been able to get her off –

stopping to wear a particular helmet. She – when she was, like, 18 or 19 years old,

she had a blood draw, and during that blood draw, she fainted. And she was sitting

down – everything was sort of according to the protocol for drawing blood because

that’s a risk – and she hit her head lightly apparently on the back of her chair or the

wall or something.

And from that point on – point in time, she developed this thought, this belief, that she

was at great risk of hitting her head and causing greater brain damage that would

increase her autism and make it even more difficult for her to live in the world. And

this is a pretty dysfunctional thought. She has all sort of other thoughts such as this.

And her parents had been, for eight or nine years, trying to convince her that she

didn’t need to wear a helmet. She had seen, from various other programs that she

had been in, other individuals who have certain types of seizure disorders who wear a

helmet in order to protect them from – during different types of seizures. And so she

decided that she was going to wear a helmet, and I forget how she acquired it. But

acquired helmet and was – had been wearing it for eight years. And this is – was

something that, you know, set her apart from a lot of other people, and she was

extremely highly verbal, highly capable, sort of high IQ. She spoke, I think, four

different languages. She was an extremely bright individual who – and the helmet was

getting in the way of her being able – she was supposed to be able to take a job, and

they told her that she couldn’t wear the hat there unless she had sort of a medical

reason and all this sort of stuff.

But there are certain types of disordered thoughts, such as this, which sort of –

overestimations obviously of how dangerous sort of the world is that really contribute

to anxiety. She really believed that if she did not wear the helmet, she would cause

greater brain injury. She knew autism was a brain disorder and cause greater injury

and would increase her autism, which is all a little sort of a bit dysfunctional, but

anxiety is not particularly rational sometimes.

The last problem, and the biggest problem with anxiety, is avoidance, is avoidance of

the fear and situation. So if you have sort of an overreactive system, and you believe

that you need to wear a helmet in order to sort of maintain safety, the thing that you

will do is always avoid any sort of situation in which you might have to sort of take off

the helmet, for example. Or if you have a fear of public speaking, for example, and

you could potentially avoid public speaking or take a sort of a different job –

And actually I’m on a behavioral program for myself in which I am not allowed to avoid

public speaking without a very good cause so – because one of the things that can

happen is that, you know, I worry people are going to think I’m not very bright. I’m not

going to get a sort of a good review at the end of my presentation. And then if I don’t

get a good review at the end of my presentation, all those things have to go to my

supervisor and sort of the head of the department, and they get reviewed every year.

And if they get reviewed every year, then – well, I mean, I have all kinds of thoughts

that are problematic.

But I could, and I did largely for most of graduate school, successfully avoid public

speaking, and it was – it wasn’t until I – my advisor said, “All right. You can’t do

anymore. In your last year of graduate school, you have to present multiple times.”

And so since that time, I have been on a sort of behavioral program where I cannot

avoid public speaking unless there’s a really good sort of conflict or various other

things. Because for a long period of time, what sort of happened? I would get

nervous. Or someone would say, “Will you present that?” And I would say, “That

doesn’t sound good. I won’t do well. It’ll be –” and then I would avoid it and essentially

avoid any of the experience of anything negative having to do with public speaking.

But the problem with that, and I could probably find a job where I didn’t have to do any

public speaking, but I probably wouldn’t then be able to work at a university where I

do, which I like to do quite a bit. And so there would be other sort of problems with

that. But if you avoid the thing that you are fearful of, you never really learn that you

can actually get over it. And now I’m not going to be the world’s greatest public

speaker ever. Maybe in 20 years I’ll be, like, a third is good as Peter Gerhart, but I

think that – but it’s actually something that I can do and get over.

And if you are always avoiding the things that are hard for you, you never learn that

you really can cope, and you never get to practice those coping skills. You never get

to practice facing your fear. And people who are anxious avoid all the time, spent a lot

of time figuring out ways to avoid the things that they are anxious about, and that is

really the thing that maintains their anxiety over time.

Depression is a little different, a little bit more complicated. But depression is also

characterized by dysfunctional cognitive styles that really lead to withdrawal, less

behavior, and less access to reinforcement. And the last piece of that is really the key

to sort of the experience of depression is that having depression, to me and to most

people who are cognitive behavior therapists or behavior therapists, is sort of

synonymous with the experience of a life of greater punishment and less access to

reinforcement.

So if you have certain types of beliefs, such as a belief that there’s no way to make

positive changes in your own life, no sort of no really way that you’re ever going to be

able to do anything good, you (indiscernible) negative events than positive events. If

you take a test or you try to do something the – and you are really fixated on the fact

that you got one answer wrong, then you’re going to feel sort of pretty bad. Unrealistic

high standards, black-and-white thinking, overgeneralization. I tried going to this event

and it didn’t go very well, therefore every event that I’m ever – I don’t want to try going

to any other event for sort of the rest of my life. Taking an event too personally. All

those types of things.

If you have all of those types of thoughts, which can develop a little bit as a result of

some types of anxiety, what do you do? You don’t do any of those things. Why would

– if you have that thought, why would you do any of those things? You wouldn’t go out

sort of in the community. You wouldn’t try very hard to get a job. You wouldn’t try very

hard at school. You might deliberately fail a class so that you get to sort of stay home.

You – if you’re trying to – or if you really believe those things, like, you’re trying to

avoid certain types of punishment, what do you do? You end up spending a whole lot

less time doing anything.

And because you’re spending a whole lot less time doing anything, you’re also

spending a whole lot less time with the opportunity to contact reinforcement. So if I

was to avoid public speaking at all times, not do it, and then develop this thought that

I’m really – which would be sort of another thing to follow would be a rational thought

that I can’t do public speaking, probably actually because if I hadn’t tried and I don’t

continue to try to get better at it, I probably wouldn’t ever get good at it. And then I’d

have this thought that I’m a terrible public speaker, and I would never do it.

But then there are certain things that would never happen for me. I wouldn’t be in

Pennsylvania. I got to see a friend of mine last night that I haven’t seen in many,

many years. I didn’t – I’ve, you know, I’ve met sort of other people. There’s a lot of

other types of things that even when you do the things that you don’t like to do that

you contact reinforcement.

So the main problem with depression is sitting on the couch eating potato chips and

watching HDTV, which is what I would probably be doing right now if I didn’t have to

come to Pennsylvania. And so but – and, you know, I get a little bit of reinforcement

for that, but those things are not as high reinforcement. And you get sick of them.

HDTV is only engaging for two or three hours. Then they start to repeat the same

shows. If you guys watch HGTV, they have about three hours, and then they’ll repeat

those same shows, so you can’t watch it for longer than three hours. You have to find

some other channel. And so that there’s a whole host of other things in my life that I

wouldn’t get to experience as a result.

And so the main problem in depression is less access to reinforcement, and those are

maintained by doing less things sort of our there in the world, and a contributor to that

is negative thoughts that you aren’t going to be able to achieve them. You aren’t –

sort of a belief that nothing sort of good is happening to you.

Now one of the things that I hear a lot, and that I try not to argue with people, is isn’t

this kind of actually, like, the reality of individuals on the autism spectrum to some

degree? That they are less likely to succeed, they are more likely to mess up in a

social situation, they are more likely to contact sort of a negative event, both – and so

the things that are sort of the negative thoughts that are associated with anxiety and

the negative thoughts that are associated with depression, aren’t they maybe a little

bit more true? And that’s a – it’s a decent argument.

My personal experience, and I think the experience of most people who work in this

field, is that those types of thoughts are still discrepant from sort of the reality of

individuals on the autism spectrum. So while it’s true that my client who I worked with

for a while, she is – misses a lot of social cues. She has a difficult time in a lot of

social situations. People make fun of her because she wears a lot of very interesting

clothes, and she loves them. And so there are a lot of different things that she sort of

encounters. She’s extremely vulnerable, probably would walk off with about just

anybody to make a friend and – but it is not true that she needs to wear a helmet

every day. And so the kinds of things, they’re usually some of the things that are the

most sort of dysfunctional are things that are still excessive thoughts for individuals on

the autism spectrum.

The other thing is is that actually the healthiest people out there are not people who

have the most realistic thoughts. And so the healthiest people are actually people who

have a little bit of false optimism about the world. So you – if you’re really thinking

about all the chances and all of the things out there that really you could encounter all

the time or all the negative things that could happen to you, the reality that I’m, you

know, never going to be Peter Gerhart, those types of things, I could feel really bad

and – but people who are psychologically healthy actually sometimes have false

optimism.

We know these people too sometimes. They can be kind of annoying actually

because they are, one, happy all of the time, and also you think that they’re wrong

about themselves because they think a little bit too highly about yourselves. But

actually, a little bit of that is actually healthy because it gets us out there into doing

those things. And if you have some optimism about the world, some optimism about

yourself that things are going to get better in your world, that the world isn’t such a

terribly horribly scary place, you do a whole lot more, and you actually contact a

whole lot more reinforcement in your life. So it’s not so bad if we sort of work on some

of these thoughts and move into places that are maybe slightly unrealistic.

So the question is – and then we’re going to talk about medication in my talk. I’m not.

It’s not my area of expertise, and so my – I don’t feel like it’s something I can speak to

as well as somebody else can to. And that – and the other thing is is that there are –

for use with ASD, there are really only two drugs, two or three drugs, atypical

antipsychotics that are approved specifically for individuals on the autism spectrum.

So it is – at this point in time, we’re still sort of in the infancy.

A lot of things get prescribed for specific comorbid symptoms and sort of symptom

reduction, which isn’t necessarily a problem, but we don’t know enough about it that I

feel like I can say too much at this time. And all of the studies that are really looking at

anxiety and depression and its treatment in ASD at this point in time are really CBT

and behavioral. So I’m limited both because it’s not my area and because mostly

what’s been studied so far is in the other area. Although certainly sort of practicing out

there is ahead of the research that needs to catch up, and so I think people need to –

I’m hoping people are getting on it. And there are some places that are doing some

trials of medication in individuals with ASD, mostly children because we tend to do

everything in ASD and children first.

Yeah. I know there’s some other groups at – in addition to the University of Pittsburg

and people at UCLA and other things that are doing some of that work, and I think it’s

going to be really very exciting. And personally, I see a lot of benefit to using both,

particularly in pretty difficult cases, is that I have found sometimes it makes it a lot

easier to learn the coping strategies if you are taking medication at the same time.

Yes, usually anxiety doesn’t really go away. It – sort of depression also. It can sort of

mask it or be the more sort of prevalent state. But yeah, usually anxiety is really sort

of thought about as a sort of temperamental thing. It’s present pretty – some

symptoms of it are often (indiscernible), and we don’t have good sort of trajectory in

ASD. But I would say in the sort of typically developing population, we have some

data that anxiety is usually much more common in children and adolescents, and then

sometime around late adolescence/early adulthood is when we see sort of the rise

and sort of spike in depression for the most part.

And we see certain periods of time in which individuals are little bit more prone to

depression, young adulthood being one, sort of late/middle adulthood being another

period of time with kind of a little bit of relief in between sometimes. But yeah, we

usually see anxiety mostly in children developing problematic often by school-age or

adolescence and then depression coming late adolescence/early adulthood most of

the time. But like anything, generalizations in ASD are not wildly useful, so we end up

with a lot of variance. I have kids who have, you know, depression symptoms by age

six or seven, and individuals who are – who have had anxiety for their whole life and

never developed depression, so there’s different presentations.

So now I’m going to turn this presentation in a slightly different direction to talk a little

bit about treatment, and there’s – I could talk a lot about treatment so I’m going to try

to do my best in an hour and a half or so to talk about it. Now best practice treatment,

at this point in time, includes at least one of the following, and in my experience

probably all three: cognitive behavior therapy, which is a type of treatment, if you’re

not familiar with it, that focuses on cognition and changing sort of behavioral patterns

that are associated with maintaining a disorder; behavioral skills training, which is that

– which in these cases is often something used to treat certain skill deficits that are

associated with the disorder; and psychiatric medication management. So I did get

my meds in there, but this is the only time I’m talking about it. But I’m not going to talk

anymore about it other than that I do use it and refer people and work with a

psychiatrist pretty frequently.

So the components of CBT for anxiety are really three pieces. And now CBT for

anxiety is not a – it’s not rocket science. So we’re – it's based upon really this last

number three here, which is really that – something that we all know is that if you fall

off the horse and you – in order to not be scared of the horse, the same thing you

have to do is get back on the horse and you’re – is that you have to, in order to get

over whatever your fear is – so if it’s not wearing a helmet, if it’s a horse, if it’s a snake

if it’s social anxiety, public speaking, making mistakes on tests, not doing well on a

date, not, you know – getting sort of rejected when you ask somebody out, not doing

well in a class is that you have to face that fear in order to really get over that fear.

Confront the fear, experience it, realize that you can actually handle it – it might not

be the most fun thing in the world, but you can actually handle it – and get over it.

Now the problem with that, if it was a really easy – it’s easy for me to say that, but if it

was a really easy thing to actually do, we’d all just do that and sort of be done with it.

But it’s actually something that, for CBT, that you spend most of the rest of your time

as a therapist trying to get to that place where somebody will confront their fears with

you, where somebody is willing to stand up in front of a bunch of people and give a

talk or somebody is willing to deliberately make a mistake on a homework assignment

that they turn in to their professor and realize that they didn’t fail the class, that they

are – you know, can misspell some words in an email and that they won’t lose that

friend. But whatever the thing that they have fear doing, that they do it and realize that

it’s not so bad and that they can actually handle it.

But this is so hard. People don’t just run out and do those really, really hard things

and deliberately experience anxiety. So you have to do some things first, and the first

piece – I’m going to talk about anxiety first, and then we’ll talk about depression

because that’s the way I always do it – but we talk about is that we have to usually,

and this is for any individual whether or not they are on the autism spectrum or not on

the autism spectrum, is that you have to talk a lot about initially what anxiety is.

Now there’s some kinds of emotions that are really easy and much more concrete

than anxiety. So for most individuals that I work with in my clinic, they’ve been taught

some about emotion at various points in time. They can identify pictures of cards for

happy, sad, mad. Usually happy, sad, mad they have, most individuals, because

those are really easy. There’s something really concrete with them. Happy, you smile

or laugh. Sad, you cry. And mad, you’re sort of having a tantrum. Now most or a lot of

other different types of emotions or other things, surprised or anxious, get a little bit –

fall into those other three sort of categories a lot of the time. That’s a slight over sort

of generalization, but it happens quite a bit.

And so you may have to really work with the individual to help them sort of build, if

they have the sort of verbal skills to be able to do this, to build a vocabulary around

anxiety. Now anxiety is sort of this clinical term, but I use scared a lot. I’ll sometimes

use another word for it instead of using anxiety because anxiety can be a tough sort

of word to get a hold of, and scared is a little bit easier. And it has a good sort of

counter in brave, so it’s a—sometimes it works out a little bit better. So but you have

to talk about it and identify it quite a bit.

And then you have to work often to help someone understand when they actually are

anxious. Sometimes anxious manifests in a lot of our individuals that we work with as

irritability, and so there are lots of different reasons to sort of be irritable or moody or

upset or some sort of version of that, but it sometimes is sort of described or the

experience of anxiety is defined by being mad or some other type of emotion.

And so I spend some time working with an individual to help them understand and be

able to identify when they are actually anxious and to understand how, individually,

they experience anxiety. Because we all experience it a little bit differently. I get

headaches and fidget and have a little bit of tightness in my stomach, and other

people have a lot of other different types of experiences. And so to understand when

I’m anxious, and I have to understand when that person is actually anxious.

And then I talk about how – to try and get sort of motivation to be able to treat it

because I’m going to ask somebody who does not want to do it to confront the things

that they’re very anxious about. And one of the ways that I can do that is to talk about

how much time anxiety takes. So when you’re being anxious, and if you are someone

who experiences anxiety on a regular basis, you can’t really be having a whole lot of

fun at the same time that you’re anxious. There are, like, a few exceptions to that rule,

on roller coasters and things like that, but for the most part, at periods of time where

you are experiencing anxiety, you’re not experiencing joy. You’re not experiencing

things, and you’ve lost a lot of time in your day to anxiety and worry.

And I will often have, when somebody is – has worked on being able to identify when

they are accurately anxious, I work on documenting how long or how much time out of

their day that they are anxious. And sometimes it’s a pretty substantial period of time.

I’ve had some individuals I work with who, once they start doing this, reveal that they

are anxious 80% to 90% out of their day, and that can be a very motivating factor.

I will externalize aniety symptoms for individuals for whom I would be able to find this

sort of useful is that anxiety has maybe something that’s happening to them as

opposed to something that’s so ingrained as a part of them that you can’t treat it or

can’t get rid of it. But that it is something that you can externalize and make into sort

of an evil type of creature. And I will show you some examples of that in a minute.

And then make a connection between sort of the thoughts and physiological

reactions. So the – when it’s possible, for individuals who are experiencing a lot of

sort of negative or anxious types of thoughts, that coming up with periods of time

where they might write or document or talk about or you might create situations in

which you might sort of induce anxious thoughts and then talk about how somebody’s

physiological reaction happened in response to that.

So that’s sort of all the goals that I try to accomplish with the education piece. And

that usually takes six to eight weeks probably in a lot of cases, sometimes more, but –

and sometimes if you’re – it depends on the individual, but often six to eight weeks

when I’m doing that over. And I do it in a lot of different sort of creative ways. To talk

about it today, I’m mostly talking, but that doesn’t work for a lot of individuals on the

autism spectrum. And so I also, for highly verbal individuals, I do a lot of analogy. And

so this is my favorite analogy, and this is something that I find that a lot of individuals

really do sort of identify with is the car alarm analogy to understand sort of their sort of

physiological system and why you might want to necessarily change it.

So we – there’s a – we all know about this, but the car alarms are getting better, so

I’m hoping I don’t lose this analogy, but that in – that there are some cars that –

whose car alarms work really well. So they only go off when someone is breaking into

the car, breaking a window, doing something that is actually sort of a danger to the

car. And there are other car alarms, usually on a BMW and particularly the one that

lives down the street from me, that goes off at all times when it’s not supposed to

cause such as when the kids – I live on a hill, and so there’s kids who ride their

skateboards down my street all the time, and it goes off when anybody’s riding their

skateboard down the street. And it goes off when a cat lands on it. It goes off at all

sorts of other times when there actually is in any danger to the car. It’s sort of a faulty

alarm system.

And I use this analogy to talk about sort of a faulty anxiety type of system is that your

– is that people – your anxiety system is supposed to go off sometimes, but there are

some – for some people, in some individuals, it’s not working really well, and it goes

off too often. And in that way, one of the individuals that I work with quite a bit, we talk

a lot about things as sort of as a real worry or a false alarm and that every time she

gets that type of thing, she has to stop and say, is this a real worry or a false alarm?

And that’s been very helpful to her, so I use this analogy and other analogies like it

quite a bit.

I also do a lot of, like, visual sort of active types of things. This is something I might do

to sort of externalize anxiety is that we – I might make certain representations. This is

one that I re-created because I forgot to take a picture of the actual thing, but I liked it

so much that I tried to re-create it. I didn’t do a very good job. But of an adolescent

who wasn’t going to school because he had a germ phobia. And high schools are

dirty, and they’re – he’s fearful of contacting all different types of germs and has OCD.

And so we, in sort of gearing up for various types of things, we would do all these

activities to sort of externalize his OCD.

And so we’d create a little things about the OCD. And this is a – this is kind of – he

made a much better cell. I think it had different actual cell things in it, and we would

squash them and do various types of things to talk about externalizing them, how we

were going to sort of conquer them and gear up for facing that kind of a fear.

I use – sometimes with individuals who are – have sort of moderate verbal skills, I will

still use some types of cognitive strategy where I really am working on helping them

identify different types of thoughts, and I will use more picture-based ones. This is one

that I used to help someone understand that how you’re thinking about something

affects how you feel about it. And so there’s two cats in this, and they’re both looking

at a sleeping dog. And one cat, the thing that’s going off in their mind is this really,

really dangerous dog with a spiky collar and big sort of scary teeth. And there is

another cat who thinks of dogs as sort of smiling and in a sort of in a very different

way. And then who’s feeling scared and who’s not feeling scared?

And using a lot of examples that I create and pull and steal from other books and

things like this can, with sort of repetition, even in individuals who don’t have as high

verbal skills as you might think are sort of necessary for this type of intervention, the

idea that you can think about something in different ways and that one – and that the

way that you think about it is not necessarily the only way to think about it. And so

that’s something that we spend a lot of time talking about is what are all the different

ways that someone could be thinking about a dog and how are all the different ways?

And if we just wanted to immediately fix how this cat was feeling, one of the ways we

could do is insert a different image or a different sort of thought. And sometimes I will

do various things where I’ll cut them out and put them there and do various things

where – to show that we really can change how someone’s feeling by changing sort

of how they’re thinking.

So I have to get creative with these, and I mess up a lot and find that I have to do it

over and over and over again and use a lot of sort of the same sort of scripted

language in some cases. In other cases, people get it right away, but in other cases, I

have to be very creative about how I try and teach these things.

But I’ve learned that – not to really give up on the sort of cognitive piece. Now people

will say – in the beginning, I was a behavior analyst and didn’t like to think about

cognition too much, and I always knew, like, the right script for a behavior analyst is

that cognition is just, you know – it’s covert behavior. We think it exists, but we don’t

really know what to do with it. And so we were – since we don’t know what to do with

it, then we don’t deal with it a whole lot.

And now, even though we still don’t always know what to do with it, we – there are

different sort of levels of cognition and that I do spend – I don’t give up on it as much

as I used to in the beginning so that I work at trying to find some way to tackle

somebody thinking differently. And it is at different levels. You had a question?

So the question is how much is done in an office and how much is done in the

community or in the environment. I work in – primarily in an office environment, and I

– you can – but it doesn’t – it can happen in just about any environment. I also do

some home-based work and usually this education portion where you’ll see the

education piece of this is done sort of in an office, and then the – a lot of the actual

sort of facing fears and getting out there is out of the office because that’s where the

fear – there isn’t usually that much that’s scary in my actual office. Sometimes there

is, but in order to confront a lot of the things is we do it in the places where they

actually sort of are. It’s a good question, and it’s one of the hardest questions

because it’s to determine what the – what it is.

And you know, it’s – individuals are not very good at giving up their thoughts, and this

is true of all individuals about our sort of private thoughts. And the easiest way to tell

is that someone would say, I’m not doing this because I’m worried that when I go to

this place, someone is not going to be nice to me or someone’s going to make fun of

me or whatever. Or somebody – or you’re going to go to this situation that’s going to

be something that they’re not going to be able to be confident about it or – and then

you might know it’s an anxiety or depression and be able to work on the thought piece

of it and –

But other than that, then it gets – actually gets quite complicated, and so sometimes I

have – you have to work for a substantial period of time, I’ve found, at giving people

to sort of give up their thoughts. And most – thoughts are not necessarily very

conscious, and there are sort of different levels of – that I think about of

consciousness of thoughts, and I’m, like, going against everything behavioral by

saying that.

But I don’t really think that I am because I think there are some things that you – that

behaviorally that happens not within your own awareness. Sometimes I fidget and I

don’t realize it, and sometimes you have a thought and you don’t realize it. And so

sometimes you have to work at practicing from other kinds of thoughts. And

sometimes you have to move them outside of the realms of anxiety or depression to

get people who – to report their thoughts or their points of view about all different –

other types of things, and I find that helps sometimes.

And sometimes I’ll – sometimes you have to go with them. So I am fortunate enough

to be able to do that, but sometimes I’ll say, we’re going to go to this thing and see if

they’ll go or interview other people or find other types of way. There isn’t really like a

magic. I was talking about this. There isn’t, like, a magic way to determining whether

or not something is sort of an anxious symptom or a depressed symptom or why

they’re sort of doing it.

And sometimes, to some degree, if you never get the thought, it can – you can still

treat it sometimes. So and it – you can still treat the idea through other types of

behavioral means to get them sort of out in the air. So sometimes, and you’ll see it

doesn’t always have to be, if it’s a problematic sort of pattern and the behavior is the

problematic piece and you know that sometimes you can treat it without even knowing

one or the other. And often really, it’s both. That they’re worried they’re not going to

be competent at it, they’re worried they’re going to be scared, they’re fearing

something at it. But sometimes you can treat it even without knowing that.

The other piece that I spend a lot of time doing, and this is something that I – that is

very common with people who work with children, but not as common with people

who work with adults, is to spend a lot of time with parent, caregiver, teacher,

whoever it is that’s in the rest of their life and giving them information about anxiety

and giving the same kind of information – most people don’t necessarily know, to sort

of the degree that we just talked about it, about what maintains anxiety, what’s

happening, and those types of things. And the difference between adaptive protection

and excessive protection. And we’re all capable of being excessively protective.

Now I do this, like, for living, and last weekend I took my niece on a hike, and I spent

the whole time moving her away from the edge. She’s seven years old and is very –

she probably could climb things way better than I can, but I spent – well, and this is

why I talk about, like, my mom and I are not doing very well at keeping the younger

people in our family from not getting anxious. But I spent a lot of time keeping her

back from the sword of the edge of the thing that we were on saying, “You should

walk on the side, and I’ll walk on that side.” And the whole time I was doing it, I was

being like, I’m being ridiculous, but – because she’s perfectly capable of walking on

that side of the trail, but –

And we have to work at this quite a bit, I think, because the reason that I’m doing that

is to manage my own anxiety really, not because I’m really sort of worried about that

other person. But that to have a lot of conversations about what it feels like to be

putting somebody in a situation where they may be slightly at risk. And you can’t get

rid of all risk in the world. It would be great if we could, but to some degree, people

will always be exposed to some degree of risk.

And with that – and we have to be okay with that a little bit and not excessively protect

and sort of have individuals so that they never experience anything sort of negative in

their life and have a conversation about how when you’re – often when you are

excessively protecting, you’re managing your own anxiety and keeping yourself from

experiencing any of that anxiety by keeping that person away from whatever is

dangerous. And talking about being a coach and a model. Sometimes I have to spend

some time dealing with other anxieties in the family.

And then once we do that, we start facing fears, and this is, like, the really unfun part.

I love putting this slide up. You guys, it’s so fun because you can see all of that. Like,

if you just – it’s just you can see all of the fears just come right out. I have – I’ve never

done the face one, but I have done the upper one. And that doing this sort of work

has meant that I’ve had to confront some things that I don’t really want to do because

it is my job to model appropriate coping sorts of strategies. So I have a – I work with

an individual who’s probably – he’s 15, I think, but about a year ago stopped sleeping

in his own room because he saw a spider in there. And if you – there’s a major – if

you guys have ever been to New Mexico, there’s a major spider problem, and there’s

all kinds of really exciting bugs.

So we deal a lot with bug – I deal a lot with bug phobias, and I often pick them as a

first phobia to kind of tackle because it’s really concrete compared to other kinds of

fears, which are a little bit more – sometimes they can – it’s a little bit more – it’s a

little easier to treat a bug phobia. But I have had to let spiders and various other

things roam on my hands in my office and in his bedroom.

So essentially the piece of facing your fears is step-by-step confronting the things that

you sort of fear, learning that you can sort of handle them. For this person, we – I

went into my backyard and captured some bugs, some dead spiders because there’s

a lot of spiders in my backyard and had them in little plastic containers. And first we

tolerated them in my office just being in the room. And then we tolerated them being –

I think having his foot be near one. I don’t remember.

But we created various types of a hierarchy where it – where eventually we got to a

point in time where we let spider, just not a black widow, but letting a spider – we did

hold black widows – not live black widows, but letting a spider crawl on your hand.

And really once you can do that, you are doing pretty well with a spider fear. And

you’re supposed to, you know, you’re supposed to have fear of black widows, so –

but that – but you’re not really supposed to not sleep in your own room because

you’re so worried that there might be a spider, and that could sort of be a problem.

Most of the time, I develop it with the client or – and their caregiver or sometimes the

staff or their parents or whoever it is is that we spend a lot of time sort of trying to rate

fears on a scale of one to five. And I use a lot of visuals for this, like where are you?

When I talk about this. How big of a fear do you think this is? And for some individuals

that we – you pick things that are really easy that you can develop a little momentum

with, and then you work on moving up sort of thing. And I usually do it with them if it’s

possible.

Sometimes with individuals who are not as verbally capable to engage in that, you

have to develop a hierarchy without as much input. And so you might do that with

other sort of other information that you have with them or – and sometimes in those

cases, I make a hierarchy that is so long that I make sure that there’s enough steps in

there that I’m not overwhelming anybody. Because what you’re trying to do is that I

don’t just walk in and let somebody say, today, we’re going to let a spider crawl on

your hand. Most of you probably in this room might not do that and that particularly if

you have sort of a spider phobia, and so –

But along with those spider phobias, we’ll tolerate looking at a picture of a spider for

10 seconds. And then you’re trying to find a place that’s just above sort of their

discomfort or their comfort level and work on that until it no longer becomes

uncomfortable. And then you move up to the next one until it no longer becomes

uncomfortable. And then you move up.

Sometimes people catch on to what you’re doing, and then they report that it’s just

staying uncomfortable for a long time because they don’t want to move up. And you

have to deal with other types of problems with that. And I tend to use a lot of

reinforcement because this is hard work to confront something that you’re anxious

about.

But while doing this, we essentially experiment at these lower levels with different

ways to sort of cope and manage what anxiety that you are sort of experiencing, such

as with different types of sort of cognitive thinking patterns, such as the spider really

doesn’t want anything to do with me. The spider’s probably more scared of me than I

am. That kind of stuff. Or I only have to do this for 10 seconds. Or whatever’s going to

get through – get that person through that particular activity and playing around with

different types of coping strategies that they can then use in sort of the other

environment.

When we do this in – this is the part that we – I sometimes try it in my office, but I’m

often actually in the environment where somebody is. So this individual once saw a

spider in the closet, and we let – one of our highest steps was to let a spider that is

not a dangerous spider go in their closet. And we hung out in the room for several

hours, and he had to sleep in that room that night. And where we are doing things

were you’re moving all the way up to a place in which your fear is really sort of

tackled.

The principal is exactly the same. For all of us, if you need to confront an anxiety, it’s

more the education piece, in the first piece, that things are more altered to – and that I

might go slower. I often go a little bit slower because my – sometimes it takes a little

bit longer to build some momentum at it. And sometimes – and I tend to use little bit

more reinforcement. So somebody who is suffering themself at, you know, age sort of

– you know, at age 25 is probably – has some internal motivation to get over

whatever fear, social anxiety, or whatever sort of thing that they’re trying to do.

An individual on the autism spectrum may not do that and may not do it to please me.

So sometimes, like, you know, a 13-year-old girl will do things in an office

(indiscernible) whole thing just because of sort of the social sort of requirements of

that kind of situation when adults ask them to do it. But I don’t find that that’s always

the case. I find some very, very, very motivated adults with ASD that I work with who

need no reinforcement to do some of these things. But then I find other individuals

really do need a lot more reinforcement at various different levels to get over it.

But mostly it’s different in the first part of the treatment, which is the understanding

and gearing up for doing this. And this is really the slow and just study steps. If sort of

the category is talking to people, you are talking on the phone or various other things,

but you would come up with a list of things that are close. I’ve had individuals that I’ve

worked with with autism and selective mutism and various other things where you are

working on talking to really anybody at all. And you might be at a level where they are

sort of recording their voice onto a device and playing it for somebody else and then

having to say a single word in front of somebody else and having to do things at that

sort of level.

And you – for something, it’s a more sort of social fear. You have to do this type of

hierarchy. But you also have to make sure that all of the skills – you have to teach all

the skills, and sometimes it’s a combination of things that you are working on where

you’re doing some things – some exposure along with how to teach that specific skill.

And I’ll start with things such as calling on the phone to order pizza or calling on the

phone to ask somebody what the hours are at this particular store, calling me in the

middle of the day, calling familiar people and coming up with ways that you can break

it down eventually to calling a friend to ask them over. And by the time –

And I won’t send anybody to do anything that they can’t do. So if it’s really outside of

their skill set, you have to build the skill first and then do it. And often, you’re doing

both of those things because they’re often related.

The question was is the – is it for a lot of individuals that have – you might come and

have – who are – or what do you do essentially when an individual is not sort of

internally motivated to conquer a fear? And that happens with a lot of individuals. It

happens with most children, typically developing or not, and with a lot of individuals.

And actually, I mean, a lot of adults show up to therapy for – because someone else

is making them go too. So there’s a lot of – it’s not a very uncommon phenomenon.

But with – in this particular problem set, what I do is find some sort of external

reinforcer. I bribe the heck out of them for the first one. I promise something big, and

the reason you don’t want to get over it is because it’s really hard work to do that and

that – so reinforcing them, I think, is appropriate. It’s a – you know, I use the word

bribe, but I also think it is reinforcing. And what I find is that once you do one or two of

those, once you get over the fear – and I do use concrete fears in the beginning often

and fears that are not –

In addition to this kind of a hierarchy, I do a hierarchy of fears. So sometimes people

will have 12 different types of fears, and I’ll start with some of the easier ones. And

once people realize that once you start to confront things and you feel better and you

feel good about yourself, you can get a little bit of internal motivation. Sometimes you

don’t, but oftentimes you realize that somebody does actually feel better. Somebody

else is sort of proud of them, and they’re proud of themselves. They’ve accomplished

something that’s been bothering them for sort of eight or nine years.

The young woman that I worked with for a long time, or I saw her, she’d been wearing

a helmet for eight years. The first thing we worked on was the helmet, and now she

will come in. She wasn’t really excited to take off the helmet, and so we first initially

started off with she had to take it off sort of, you know, in my office. And then we had

to – we slowly sort of grew the period of time that she – and we – I reinforced her, or

her family did, with People Magazine and pictures of Leonardo DiCaprio, and so she

– which is, like, her favorite thing to talk about and –

But once she got over it, she was very proud, even though she was really wedded to

that thing for a long period of time. And sometimes she’ll still come in, and it’s been

about two years since she’s worn the helmet, and she’ll still come in and say

something to me like, “I’m doing good, right? I’m doing good. I’m not – I didn’t wear

the helmet.” And that they’re – that even – that some of those things really can sort of

catch on.

And once we did two or three, she is – she’s more likely to be there with me.

Sometimes she’ll – she still thinks I’m crazy sometimes and that the things I’m asking

her to do are horrible, but it’s a lot easier now. But the first couple, you have to find

external reinforcement. There is no internal reinforcement. And so it’s the same thing

that you do for anything that you want somebody else to do that you feel is worth it.

You have to bribe them.

For several years, I worked on a – during my postdoc, I worked on a project where we

were – we required different types of blood draws and various types of things to sort

of research, and so that’s where I first started doing this. And I’ve done it a few other

times sort of across, and usually what I find is that you have to do a really good job

with sort of with your hierarchy is that you have to go all the way down to a point at

which they actually can do something so – and it’s not particularly aversive to them at

that point in time. So that might be potentially talking about going to the gynecologist,

and it might be driving by the gynecologist. It might be reading a story about

something related to it. But that you do actually need to go down all the way, that you

have to go all the way down to a point in time in which you really can.

And sometimes you have to change doctors because sometimes the office isn’t as

sort of cooperative as you sort of would like. And then sometimes you have to find a

different doctor that will do that. But I think usually the problem is often one of not

going all the way down to where you can find something that you can reinforce and

then finding enough small steps. So it might be then that you go sort of into the office,

and you’re just taking off your shoes. And you’re going into the office, and you are

finding something that isn’t so aversive that you can’t find something to reinforce it

with. And so you have – sometimes you have to go down to a level that feels almost

ridiculous.

And then there are other points in time where you – where sometimes you pick your

battles. How often does that have to happen? And for some people – yeah, I mean,

sedation is not fun. But you wouldn’t always choose based upon your priority list

because you can’t tackle everything that everybody is always – is that sometimes it is

okay that for sort of that appointment that you need every other year or whatever it is,

depending upon your risk or various other things recommended by your doctor, that

the procedure is sedated.

So the question is what do you do with a fear that doesn’t – that has – is more of an

internal, and it doesn’t have a – what?

Participant: That’s rational.

Presenter: That’s rational. Oh, well, that’s another question is – yeah. I mean, some – there are

some – often some rational sort of piece of it, and yeah, we are – we could all be

spending a lot of time worrying about dying, and that’s a possibility, but it’s not

particularly sort of enjoyable.

Now they’re usually things that, if it’s a problematic kind of fear, they’re usually things

that somebody is doing in order to keep themselves from dying or avoiding as a result

of that. So having any sort of fear of dying isn’t – I guess I have a fear of dying. I don’t

think about it very often, but most of us probably have some level of fear of that. But it

becomes problematic either if you’re thinking about it all the time or you start to avoid

certain situations that it doesn’t make sense to avoid as a result of that.

And so those are the things that you end up having to work on. So this young woman

that I work on that I use as an example a lot is – she’s primarily worried about her –

one of her core fears is that her autism is getting worse. And so she has a lot of other

little things that she’s picked up sort of along the way of – like the helmet and various

types of things that are sort of related to that. And so often there are actually sort of

behaviors that somebody will do, sort of either excessive health keeping-type

behaviors, excessive washing of their hands or – and those are the things that you

put on the hierarchy and –

Or you do some sort of form of hypothesis testing. So I will come up to convince

somebody that they should have a different sort of way of thinking. And they’ll say, “If

I do those sorts of things, I’ll put myself at sort of a greater risk.” And so you go out

and sort of test the various sort of hypothesis about whether or not your autism is

getting bigger, about whether or not you’re sort of potentially sort of likely to die. But

usually there’s a behavior that’s associated with it that is problematic, and that’s the

one that you’re working on with the hierarchy. Otherwise, you’re working mostly on

thoughts.

But I caution you not to argue about those things very much because if you try –

arguing with people doesn’t really work and arguing with people on the autism

spectrum doesn’t – really does not work at all. And so if someone has a fear of dying,

I – my approach to that is to say, “Yep, it’s quite possible ya’ll eventually will die.” And

it’s not to necessarily argue about it, but I will say that, what are the things that that

fear is leading them to do that are maladaptive? And that’s the stuff that I work on.

And then you’ll find that that thought will change because your thoughts are not – your

thoughts really more go in line with what your behavior is. So if you’re avoiding

something, you’ll come up with a reason why in your mind and that the reason will get

a little bit – sometimes get a little bit more creative. And so if you stop avoiding

spiders, you eventually will not think they’re as dangerous, and if you – you know, that

type of thing. And if you stop washing your hands for, you know, four hours a day,

you’ll have a smaller fear of dying as a result of contracting something with that.

There are some problems that don’t get fixed this way and that there are other

solutions around medical problems. But the medical fears are a really big one

because our guys have to spend – make more doctor visits and often have a history

of unfortunate things happening in certain doctor’s offices or other sort of procedures

that make them sort of more likely. So in some cases, for an individual who ends up

needing to go to the doctor quite frequently or needing certain types of procedures to

be done, it is worth going through something like this. Other times, it’s not. But it’s all

about what your priorities are at that point in time. But yeah, sometimes, if you’re

going to do it, you do, like, everything you can at that point in time.

Depression is a slightly different piece, and often I’m doing both of these things at the

same time. But these are the general components that I use in depression, in treating

depression: psychoeducation; parent, caregiver, teacher, whoever it is education;

self-monitoring of pleasant events; pleasant event scheduling; increasing positive self-

statements; learning to handle disappointment, and that’s another thing we’ll talk

about.

So the first piece of most treatment really is – and that I do with both anxiety and

depression is to talk about a vocabulary around depression, learning to understand it

in the same way that I would talk about it – the same kinds of stuff that I would do with

anxiety to be talking about how you – on a sort of a different type of scale, where your

mood is. And I usually put it on a scale. And we talk about – and I do some of the

same types of things, talk about how much time it takes, how much it interferes, about

how something’s happening to you and make a connection between sort of your

thoughts and how you’re feeling.

The – a lot of the early part of treatment with individuals with ASD, when I’m talking

about depression, is the self-monitoring of pleasant events and unpleasant events. So

what I find is that when a lot of individuals come into – get to me, they’re often fairly

depressed. Depression doesn’t get caught as early as anxiety nearly as often, but –

and – or it gets thought of as something else a lot of the time.

But by the time they get to me, they often have two categories of events in their life.

There is the events in their life that are really, really awesome and great, like the Wii

and Angry Birds or whatever it is. And then everything else is, like, horrible or awful

and has no sort of enjoyment, and it’s actually something that they report is, on a

scale of one to 10, is like a one or a zero. And then there’s all these things that are,

like, 10.

So if I was to create a list, everything – you’ll see this sort of, like, dichotomous

pattern in individuals is that they don’t have a whole lot in the middle, and they’re

often a little bit wrong about a lot of things sort of in reality, what they themselves

would rate.

Now we’re a little bit like this too. This is not sort of a unique thing to individuals on the

autism spectrum. But I can tell you some things that are like a 10 for me. If I could

pick anything to do on a given day, it would be go to this spa in Santa Fe called Ten

Thousand Waves, which, if you ever go to Santa Fe, you should go to. It’s, like, high

up in the mountains, and it’s this great sort of spa, and you get a sort of – they’ll give

you fabulous massages. It’s a beautiful place. That’s, like, my number sort of 10. And

there are a whole lot of other things that I can say.

And then there’s a lot of things that I have been wrong about where I’d place them.

For example, a friend of mine recently talked me into running for Team in Training for

the Leukemia & Lymphoma Society. And so I thought it was going to be, like, the

worst thing in the whole world. If someone had asked me on a scale of one to 10

where running a half marathon would be, I would put it at a one. But actually doing it

and actually going out there and realizing – as I was running, I realized, wow. While

I’m actually running, this isn’t so bad, and I would probably rate myself at a four or a

five. And then right after running, I feel pretty proud of myself and pretty good, and I

actually feel much higher than that.

And so in a lot of ways, we’re not always very accurate reporters of what things are

good for us or bring us sort of good feelings or not good feelings. And so what I –

what the sort of the treatment for depression at its sort of core is to get people out

there in the world experiencing more positive things, and that is one of the sort of key

pieces to it. There are some other components, but one of the most important, most

powerful things is to get people out in the world experiencing things. So I challenge a

lot of people that I’m working with to go and test out all different types of things and

monitor them and rate them.

And sometimes they’re surprised. Sometimes they came back and told me that it was

just as awful as they thought it was going to be. But other times they come back and

they discover that there are some things that really weren’t so bad. And that if they

tried them again, they were actually even better than the first time. Because what I

think is – sometimes happens with individuals is that their world of positive things has

gotten very, very small. They’re usually things that are within their home, often

attached to the computer or video games or special interests or various types of

things, and the number of things that they really enjoy or know that they enjoy, know

how to access and contact themselves, is pretty small.

And so we spend quite a bit of time in the beginning sort of monitoring different types

of pleasant events, and then we conduct a lot of studies. One of the great things

about individuals, particularly higher verbal individuals, on the autism spectrum is

they’re actually very convinced by data, which is great. So very objective types of

things, and so you can take on the role of being an experimenter.

And I never – I don’t – I try not to argue with anybody ever, but I really don’t argue, as

I mentioned before, with a lot of people with autism. And so one of the things is we

come up with sort of experiments. And I say, “I don’t know if you’re going to like this,

but let’s try it five times, and let’s rate it and do various different types of

experimenting types of things.” And I do this with anxiety too.

This one person that I worked with, and this is a – I’m going to go back to anxiety just

for a minute because I love this story – is of a woman who was 25, and this was a

thing that we really had to tackle early on in our treatment so that I could continue

working with her. But she was really concerned about getting older, and she thought

being 25 was really old. And that was a bit of a difficulty for me and being significantly

older than that and was also the thing that, like, other people – and she would offend

lots of people all the time by saying sort of inappropriate things. But she had this fear

that if she told people sort of her age that they would judge her sort of poorly.

So we ran a whole bunch of experiments where we – for each experiment, we had to

poll 100 people about what they thought about different people. So we had – we

came up with an experiment such as there was a 22-year-old person, a 25-year-old

person, and a 32-year-old person, something like that and had this sort of description.

We read them to people, and then they had to rate them positively. And there was no

difference between sort of their ratings between all different groups based upon age.

And we did other kinds of experiments where she had to then tell somebody her age

and – which she hadn’t done in – I don’t know – four or five years since she’d turned

20. And she – so she hadn’t – and she had to tell somebody her age and look for any

cues that they were treating her any differently. So we would come up with these kind

of things and gather a lot of data, and she’s now – I think she’s approaching 30 so –

and she’s doing – I think she’s still doing pretty well with it, so I don’t know if she’s

going to have a little bit of a setback at 30, but we’ll see.

And then once you know about what present events and the sorts of things that cause

you to experience more sort of pleasure and joy is to then plan for them and schedule

them. So these are the positive activities: going to a movie, riding bikes, going

swimming, playing baseball, renting a movie, that type of stuff that then you plan for

them and find ways to successfully achieve those outcomes.

So while I – in anxiety, I talk about cognition first. I usually don’t talk about cognition

first in depression. I usually talk about behavior and planning for pleasant events first

to get a little bit of sort of momentum, a little bit of feeling better before we start

working on cognitions for those individuals who do. And so I talk about – and usually

during that period of time, I’m trying to figure out what their thinking errors are. But we

talk about different types of patterns of thinking, and some of those are – some of the

very common ones are problematic types of thinking are black-and-white thinking.

So if I didn’t do it perfect and I didn’t get an A on my paper, then it was horrible. If I –

my GPA wasn’t a 4.0, then it sort of wasn’t good enough, and I have to sort of be

perfect. Or I’m so terrible at this. There’s no way I’m ever going to be able to do this.

That there’s a lot of kind of dichotomous type of thinking, and a lot of always and

never and those types of things in terms of different types of thinking problems that I

see in autism spectrum disorders.

I see a lot of things like fortune-telling, sort of the little phrase that I call knowing

what’s going to happen after something. And then we usually challenge that with an

experiment of some kind. I know if I do this, I won’t be able to do – I’m not going to

bowl very well, and everyone’s going to laugh at me. And then if everybody laughs at

me, I’m – I can’t, you know, keep going to that college event or whatever the type of

thing is. And I can argue with that person and say, “Everybody gets a gutter ball from

time to time, and everybody laughs. But that doesn’t necessarily mean that no one’s

going to like you or any – that type of thing.” And I can argue with them.

Or we can run an experiment. And then I say, “If everybody laughs at you, you don’t

have to do it again.” And usually I only do that if I’m pretty sure that they’re not going

to get – that we challenge those different types of thinking areas and talk about them.

And I – we – I find that this often takes a lot, a lot, a lot of practice and a lot of

diagrams of different ways that you can think about the same situation so that you can

practice thinking about it in different ways.

And I also use same types of analogy. This is one that I use a lot. And I find it true of

a lot of people who are experiencing depression is that they have this sort of domino

thinking. And this is one I personally identify with quite a bit, such as that if I don’t do a

good job during a particular presentation – like I’m losing my voice right now, so I’m

having that thought at the moment. But if I don’t do a particularly good job with this

presentation, I’m not going to get good ratings, and this goes back to my boss. And

then my boss at my work is a person who will say whether or not I’m eligible for going

up for promotion at sort of my job, and then if I don’t – and if they don’t think I’m a

good sort of teacher or public speaker, which is part of my job description, then I won’t

go up for promotion. And then if I don’t go up for promotion, then I’m going to have to

lose my job and move to another state. And I’ll have to sell my house, which is very

hard to do in New Mexico.

And so you can get to a place, all because right now I’m losing my voice, but you can

get to a place where your thinking has lost some level of – and this is where I feel,

right? I feel all the way over here that I might lose my job and my house, have to

move to another state and figure out a whole new life.

But in reality, I’m probably just getting some sort of thing in my voice and losing it, and

nothing terrible is probably going to happen to me. But that we experience things all

the way over there, and how – you know, and I can use that example of those types

of things. And people would be like, “You’re not going to lose your job.” But it seems

really obvious to some individual, and often to the individuals that I work with. But they

are going all the way out there with their fears quite a bit as well.

But one of the things I spend a significant amount of time is to have appropriate

expectations for what’s going to happen in life. Now life is not always fun. There are

disappointments and there are unfun things that happen to everybody sort of in their

life and that – and the thing about that is that you have to learn how to sort of pick

yourself up after that.

And so these are some of my favorite quotes about that. The first one is, “I’ve not

failed. I’ve just found 10,000 ways that won’t work,” by, like, our greatest adventurer of

all time. The second one is my very favorite one, and it’s by Michael Jordan who –

and I love using it in a presentation because people get it. Most kids nowadays, I

don’t know if a lot of teenagers – they don’t really get Michael Jordan, how great he

was, but – and so I don’t get to use this quote, but it’s – I’ve missed –

This is for someone who’s, like, the greatest basketball player of all time. He knows

that he’s missed more than 9,000 shots in his career, and he’s lost almost 300 games

in that time. So 26 times he’s been trusted to take the game-winning shot and missed,

and he’s failed over and over again. That’s why he’s succeeded is because he went

out there and did it again after that.

And I’m still waiting on somebody like Lebron say something this good, but I’m

probably – he’s probably not going to say something this eloquent. So I might just

start to change it as something that he said, but actually, it’s something Michael

Jordan said. And the last one is something my grandmother always says whenever I

go through a breakup is that I have to kiss a lot of frogs before you find your prince.

So some other components to things is what you hear a lot with managing anxiety or

depression is incorporating relaxation techniques, and it’s great. I do that sometimes.

Most of the time, by the time an individual gets to me though, they’ve been told to

take three deep breaths and sort of clinch or do something 100,000 times and often

haven’t been taught sort of really well how to do those types of things because

they’ve been taught in the moment or whatever.

So I find that sometimes those techniques have been a little bit ruined for me by

people who are really well meaning, but didn’t teach them really effectively. And so I

use them sometimes, but often I’ll use other types of planning for relaxing types of

activities such as listening to music or swimming or doing yoga or doing something

else that induces regular – so it’s the periods of time of more relaxation rather than

learning to cope in the moment with taking three deep breaths and counting back

from 10, which can work, but it doesn’t always work the way you want it to.

I also spend quite a bit of time working on sleep, hygiene, and nutrition. There’s often

– I think my personal view is that individuals who are sleeping well and taking care of

their bodies and eating well feel a lot better. And there are often some things within

that to work on.

And then I – this last component was something that we’d touched on because we do

have a lot of individuals who come through who do need sort of outside bribery to get

them to do it. So I spend a lot of time making contracts with individuals that we’re

going to do these different things, and at the end of that, this happens. I often make

formal contracts and sign them. It makes them seem real official.

The other thing that’s been coming out, and this is not going to shock anybody I don’t

think, is that increased independence of any kind, daily living types of things and sort

of self-care, is associated with less anxiety and depression. So the more – for

individuals who are adults, the more that you are independent that you are and the

more that you’re able to sort of take care of yourself, sort of the less depressed and

axious you feel and that there’s been some research showing that teaching of those

types of skills, and specifically teaching vocational skills, not necessarily even having

a job, but having certain types of skills and feeling good about having and acquiring

those skills is associated with less anxiety and depression.

So I usually spend some time getting people involved in something, if they’re not

already. And in New Mexico – I don’t know what it’s like so much here, but in New

Mexico, most of the individuals and adults that I work with are not doing anything

during the day, probably maybe 90%. So we spend a – I spent a lot of time

connecting them to resources to get that training happening. And I also do other types

of sort of related behavioral skills training, things such as social skills, assertiveness

skills, problem-solving skills and other types of things that will help an individual sort

of contact more reinforcement in their life.

And then I work on helping either families or caregivers or employers, other types of

people, to understand what kinds of things are actually really helpful. So in anxiety is

that you – is these are some of the things that we help – I help people to do, such as

rewarding brave – any type of brave, nonanxious behavior; ignoring any unwanted

types of avoidant behavior; prompting coping behaviors; developing certain scripts

that everybody knows to talk about those problems; modeling brave, nonanxious

behavior is a big one; remaining calm throughout those situations.

Anxiety is contagious, and you might sort of notice it. It’s biologically you’re supposed

to pick it up from other people and so learning how to remain calm and manage your

own anxiety during an episode in which somebody that you you’re either working with

or parenting who has anxiety and communicating empathy without helping that

person sort of avoid a thing that they are avoiding.

Things that are unhelpful: excessive reassurance that something is going to be okay,

being too directive, allowing avoidance, becoming impatient, or modeling anxious

behavior. And sometimes we have to work on those things. I often have to work on

excessive reassurance quite a bit that,yes, we are going to do this. Yes, this is going

to happen. This is – and all those little seeking reassurance-type behaviors that some

of our higher verbal individuals do do, by doing them, they’re sort of – and getting

reinforcement from somebody else that everything is going to be okay is sort of

reinforcing the whole class of anxious, seeking behaviors.

Depression. Rewarding any type of active behavior, coming up with ways to reward or

reinforce getting out and doing just about anything. Using positive discipline. One of

the big problems about people who are depressed is that they’re not really fun to be

around. They’re in fact really, really sort of the opposite. They – you feel like you have

to drag them sort of do anything and that they end up being not sort of the favorite –

so either the favorite client or get into sort of a thing.

And so one of the things that I – that we talk about a lot is that you don’t want to turn

sort of one negative person into two. And what happens a lot in depression is that,

one, is that it’s a little contagious too and that often people who are depressed get

either nagged a lot or criticized a lot or those types of things. And that’s not

particularly helpful. Learning how to remain calm; learning how to use positive types

of discipline strategies as opposed to controlling types of discipline strategies;

promoting healthy sleep, hygiene, eating patterns.

And then I was going to talk about two case examples, but first, let’s – well, what do

you want to do? Do we have questions? Or do we want to do cases or –

Participant: Cases.

Presenter: Cases. Okay. So let’s do Alexander. So Alexander is a young man who, when I met,

he was about 16 or 17. And I met him because I work every summer at a camp for

individuals on the autism spectrum that is one of my very favorite things that I do in

the whole world. It’s a sleep-away camp in the mountains in New Mexico. And he was

at the – for many years, even though his family is very involved in the autism

community in New Mexico, refused to go to camp because he didn’t want to be

someone who’s identified as a person with autism.

And he – and I think we’d tried to get him to go for several years. But once he turned

18, he agreed to go as, like, a staff sort of helper, and so he – and he went. And I met

him or I became sort of concerned about him because he – his major – one of his

major difficulties was social phobia, and he was not particularly good, as many

individuals are, interacting successfully with other peers. But he’s remarkably good at

interacting successfully with adults that are older than him, sort of near his parents

age.

And he is the most helpful person you will ever meet in your entire life. He is so

helpful. It’s a very sort of almost – well, it is kind of a pathological helpfulness. And the

reason is that – the reason it’s so challenging is that, by being helpful, he’d learned

that he could hang out with the adults all the time and never have to be around

anyone else his own age. He could – he learned at school when he was in high

school that if he helped out in the office sort of at lunch, he wouldn’t have to go to sort

of the lunch hall and those types of things.

And at camp, he had avoided for years going to camp, which his parents had tried to

convince him to do. And then once he finally did, he spent his whole – he spent the

whole time at camp helping and that – but he was so overly helpful that – and it’s so

hard to not reinforce helpful behavior. So he was reinforced all the time for being

helpful by other adults, and it was kind of charming.

But 19-year-old boys are not really supposed to be that helpful. And so it’s a slightly

sort of a – that’s – and that’s probably when I sort of realized that he had – I really

realized that it was problematic during a period of time where all the staff were trying

to pull a prank on – because we do lots of pranks at camp because that’s what you’re

supposed to do at camp is you pull pranks on people. And so we were pulling pranks

on the sort of director of the camp and some of the higher-level staff, and he wouldn’t

do it.

And I – and then I forget what some of the pranks were. And then there was another

period of time in which he – we were going to be putting pies or running in the middle

of this activity and putting pies on other people’s faces or something like that made

out of whipped cream, and he offered in the middle of it to help do something else

because he couldn’t tolerate the idea of putting a pie in somebody that he liked’s face

because that was something that didn’t really make a whole lot of sense to him. But it

was partially because of the difficulty with that sort of social situation. But I could see

how his helping – and I couldn’t get him to not help for the rest of sort of that day, and

he just helped and helped and helped.

And so I said – and that’s sort of how I met this guy. But we started working about one

day a week, and we spent probably six to eight weeks on helping him to understand

anxiety. And then I spent – I had to have a number of sessions helping his parents to

understand that what we were going to do was to try to make him less helpful

because he’d learned this sort of set of behaviors that was really sort of interfering.

And his parents were not really excited about that because he had been so reinforced

for this for such long period of time. And it’s such a charming behavior.

And so once we sort of got over that, we started to systematically plan different sorts

of things that don’t – that fall into the category of unhelpful behaviors. We had to – he

had to not help people. He had to deliberately do things that were a little bit the

opposite of sort of prosocial, I guess in some ways, but that were appropriate for a 19-

year-old boy. And he had to sort of do something that was teasing and do something

that was joking, and he had to pull practical jokes on people, and he had to – what

were other things that we did? I think we TPed people’s houses, and we did –

sometimes my job is very fun. Sometimes I’m holding spiders, and sometimes I’m

pulling pranks on people.

But we came up with a whole sort of set of things that are – that were sort of things

that would fall outside of this helpful sort of class of behaviors to realize that people

will like you and people – if you’re not just sort of helpful. Because he had a lot of –

the only way – his sort of thought was, the only way people will like me is if I’m

helpful, and I only really know how to be helpful with adults.

And we started doing this, and about – after doing this, we sort of saw – about six

months into it, I sort of saw an explosion of a whole lot of other things. He tried to,

right at 18, go to college and was unsuccessful because he was too anxious and –

but after we sort of – he learned how to be silly, and he learned how to sort of get into

some of these things. He’s now attending UNM almost full-time, and he’s involved in a

couple of groups there and is doing really well. He’s one of my favorite cases and the

most fun sort of to work with because we – and he’s a sort of a simpler one.

The other case is the case of the woman that I was going to talk about, and I always

end up ruining her case because I talk about her doing my presentation, and she’s a

29-year-old female who’s – who – and she’s a – she’s the one who speaks multiple

different languages. Her full-scale IQ is about 70. She has a sort of odd skill in the

ability to speak in a number of different languages fluently. And her verbal skills are

around 110, and her nonverbal skills are significantly lower. Very, very odd. Very, very

large split.

She has ASD, was diagnosed very, very, very young, and was – has been in and out

of sort of psychiatric hospitals from about – I think the first time she was there was

about 12, and she’d been in and out of various types of hospitals and residential

treatments until I met with her. And we first started working on anxiety because it was

nicely sort of concrete, and we conquered anxieties about – mostly related to, first,

things wedded to her autism getting worse because she was really worried about

getting worse. And then she’d be – like, have a harder time being made fun of.

And so we got the – sort of got rid of the helmet. We sort of got her involved in a

program for self-advocates where she learned to talk about and sort of have sort of a

positive self-view around having autism. And we started working on a number – we

worked on a number of other little fears that she had about – she had certain fears

that if she was – if she brushed her hair that it would – that she would lose too much

hair, and then it would be gone forever. So we had – we worked on a number of

different types of fears sort of up through a hierarchy with her. And over time, her

anxiety got sort of significantly, significantly better.

And then we started working on getting her a little bit more sort of out in the

community and planning positive events. The time that I met her, she wasn’t doing

anything during her day. And at this point in time, she is enrolled in two art classes, is

taking a French class, is – also to fun types of things. She volunteers a couple days a

week, and right now actually, she is in Spain working for two months as an advocate

for – because she speaks Spanish fluently in a sort of region of Spain which doesn’t

have a lot of autism services. And so she’s doing some education, public speaking

types of work about having autism, and she’s doing that for two months in Spain.

And this is about – so when people say, like, can it really make a difference? She’s

my favorite case. So I’ve been working with her for two years, and at that point in

time, she was wearing a helmet and was – didn’t – wasn’t doing anything during the

day, didn’t have really any friends. She now has one reciprocal friend. She has a

boyfriend and – a young man that she met in her advocacy group who has Asbergers,

and they talk every day for – I don’t know – three or four hours a day on the phone.

And she – her – and her quality of life is just dramatically, dramatically different. And I

would’ve said, and I would’ve been probably – maybe five or six years ago, if

somebody said – if I’d seen her reports and I’d seen her, like, the stack of stuff that

she came in with, the stack of all the medicines that she’d been on – she’s still taking

some meds – and all of her testing scores and where she had been, if I would’ve

thought she would be doing as well as she is now, I probably wouldn’t – I wouldn’t

think so, but –

All right. So those are my – that’s my short versions of those case examples, and then

I’d like to open it up for any questions that you guys have. There are some references

and resources. These are my favorite things. There’s others out there. These are my

favorites. And like most things that I know, in fact all of them, someone else has

taught me. These are the people that, if you – that sort of taught me everything I know

about anxiety and depression and are my very favorite people who, if you want to go

out and research more about, do some really great work. So questions?

At sort of best is that it is somebody, a therapist, a licensed therapist who knows CBT

and has worked – knows CBT and has worked with sort of the population is my best

recommendation. Now there are certainly things that people can do and that can be

really helpful. A couple of those books, there’s stuff in there that is actually sort of

quite helpful and they echo some of the things. And people can certainly do some of

the work on their own. I – the best practice really is probably with a therapist who’s

trained in CBT because it’s a simple concept. It’s not – but it’s not easy. If it was easy,

we’d all have just sort of done it. We’d all get ourselves off the couch and doing

things, and we’d all confront all our fears, and we’d all be wonderfully psychologically

healthy, if we could do it really easily. So people who have gone through –

Participant: What exactly is the training then?

Presenter: So the training would be – well, sort of best would be – there isn’t, like, a separate –

but somebody who has, I think, a license and sort of documented training. And I

would interview somebody about whether or not they know CBT and whether or not

they have done it, and whether or not they’ve received supervision in it. There’s no

sort of really standard sort of programs. What area do you live in?

Participant: I live in Chester County.

Presenter: Okay. Chester County is – it’s near here?

Participant: Yeah.

Presenter: Okay. (away from mic) Yeah. An hour east? (away from mic) Yeah. Yeah. As far as

Philadelphia, in Philadelphia, there’s some of the worst – the best, not the worst –

some of the best people who train CBT in Philly, and so there are some – there’s

some great programs there, so it shouldn’t be too hard actually. (away from mic)

Yeah. (away from mic) Yeah. They’re pretty great, and there’s people that – at CHOP

and the various other places that do that kind of stuff. There’s a lot of people who

probably come out of the internship programs, psychologists that come out of the

internship programs there that have done a lot of work.