April 23, 2024

Episode 61:

How to Use CBT with Autistic Adults with Tara McRae

In this episode, Tara shares how to use cognitive behavioral therapy with autistic adults.

Episode 61: How to Use CBT with Autistic Adults with Tara McRae

Show Notes

Kayla: Welcome back to the Designer Practice Podcast. And I’m your host Kayla Das.

In today’s episode, Tara McRae, social worker and psychotherapist, will share how to use cognitive behavioral therapy with autistic adults.

Hi, Tara. Welcome to the show. I’m so glad to have you here today.

Tara: Thank you so much, Kayla. It’s really nice to be here. I’m glad to have the opportunity to share about this topic. It’s near and dear to my heart. So yeah, thanks for having me.

Kayla: Well, thanks for being here. Before we dive in, please introduce yourself, where you’re from, tell us a little bit about your own practice journey, and what led you to working with autistic adults.


Tara: Yeah, so I am Tara McRae, as you mentioned. I live in Ottawa, Ontario. And a little bit about my journey. So, I did an undergrad in psychology with a minor in social work. And then I did a Master’s of Social Work as well. And much of my career, has been supporting autistic adults and adults with intellectual disabilities in more of a system structural kind of role. So, a lot of training, coaching, consulting with hospitals, consulting with group homes when the individuals were really struggling with their mental health and with crisis situations. So that was a lot of my career early on. So, I got to know the system here in Canada and then somewhat in the US as well. And the way that people are treated.

While we were really working from a person centered, trauma informed kind of lens. And one thing that I noticed throughout that time was the lack of psychotherapy support for this population. Because we were consulting and we were really trying to connect people with the right resources. I was like truly never finding psychotherapy support for autistic adults. So, when I started venturing into the direct psychotherapy world it was really important to me to be able to offer that service because I saw such a lack. And unfortunately, what was being offered instead of psychotherapy was Applied Behavior Analysis, and even if it wasn’t Applied Behavior Analysis, it was kind of along those lines, very much stemming from like the institutionalization. So, very important to me to be able to offer this service.

CBT and Working with Autistic Adults

Kayla: So, can you explain to us now, I know there’s lots of therapists and coaches listening, but just for anyone who may not know, what is Cognitive Behavioral Therapy or CBT? And then also, how can CBT support autistic adults?

Tara: So Cognitive Behavior Therapy is a structured style of therapy. It was created by Aaron Beck in the 60s and its typically for anywhere from 4 to 20 sessions. It’s really very evidence based. There’s a lot of research has gone into this therapy and it’s recommended for many mental health conditions because the evidence shows that it really does work.

So, with cognitive behavior therapy, in a nutshell, we’re looking at how thoughts, feelings, and behaviors relate. And then we’re doing things such as like cognitive restructuring and reframing interventions such as distancing, looking at automatic thoughts, beliefs, and then we’re doing things such as like exposure and experimenting. So, looking to see how we can get to know those beliefs and those cognitions, and then how can we maybe act differently once we’ve shifted those beliefs. So that’s kind of CBT in a nutshell.

And when it comes to CBT with autistic adults, we’re looking at how we can adapt CBT to work with autistic adults, and one of the resources that I tend to consult generally for anyone that I worked with is called the NICE Guidelines, so it’s the National Institute for Health and Care Excellence, it’s out of the UK. So, they kind of propose guidelines based on the most up-to-date research for many mental health conditions. And so, it’s a really helpful resource, there doesn’t really seem to be a similar kind of resource in Canada or the U. S. that I’ve been able to find. So, I consult these guidelines. And even there, they suggest for autistic adults that when you’re treating comorbid mental health concerns, that you adapt CBT. So, there is that guideline, right? And then there’s also emerging research indicating that CBT is beneficial for autistic adults. For instance, in treating specific phobias, PTSD, OCD, social anxiety. And yeah.


Kayla: Fabulous. So, I know you talked a little bit about ABA or Applied Behavioral Analysis. How is that different than, say, psychotherapy or cognitive behavioral therapy?

Tara: Yeah, so I think that there are a lot, a lot, a lot of differences between ABA and CBT, so it would be very hard for me to go into a ton of detail around that. And I just want to preface by saying I did not study ABA. I want to just situate my perspective here.

So, I witnessed ABA being practiced very widely in group homes and by certain agencies with autistic adults, and especially when there was a comorbid intellectual disability. And a lot of the interventions that I witnessed were based on this idea that there are four functions of behavior. So, ABA sees behavior as stemming from four different functions, whether it’s sensory, escape, attention or the desire for something tangible. And so, for instance, I witnessed a lot of group home workers being guided to– if a person was acting in a certain way and that was considered to be problematic. If that was considered to be for attention, then the intervention would be to ignore. Or if a person was acting in what was considered a problematic way or behavior, in order to get out of a situation, you would have them stay in that situation. Okay, so this is just like some examples of what I’ve witnessed. I think you can already kind of get a sense that this is very different from CBT.

And the other perspective that I’m coming from is that when I did my master’s, I wrote my thesis. I interviewed autistic adults and adults with intellectual disabilities, as well as a parent of people with intellectual disabilities who had negatively experienced ABA. And what resulted from that, a lot of different things. But some of the themes were that people felt that they were being infantilized. People felt that they were being treated as animals. That this was an extension of this institutionalization, that it was looking to create normal people and remove autistic traits or force them into being neurotypical, right? So, already you can kind of see the difference between ABA and CBT.

Medical and Mental Health Comorbidities

Kayla: That makes sense. So, from your experience when working with autistic adults, are there specific medical or mental health comorbidities to assess for and consider when providing therapy to autistic adults?

Tara: Yeah, so the main thing that, comes to mind when you ask this question and that I think is really important to consider is the idea of, not diagnostic overshadowing. So, we want to keep in mind that the prevalence of mental health conditions, within the autistic population is actually higher than the general population. I often see diagnostic overshadowing occurring which means that various practitioners, hospitals are notorious for this, they’re assessing everything that’s occurring to a person or all the struggles that they’re living through that lens of them being autistic, right? So, we want to keep in mind that there are mental health comorbidities that exist for autistic adults.

Remembering that an autistic person can also struggle with social anxiety, even though, because of their autism, they might not having as much ease in interpreting social interactions, right? But you can also have social anxiety. Or they may have OCD, along with the fixations that they have, or the special interests that they have, right? So, both those things can coexist, and it’s not just all because of the autism.

And so, when I’m working with autistic adults, though I can’t diagnose mental health conditions, I’m always keeping in mind what is stemming from the autism? What is stemming from those other comorbid conditions?


Kayla: Perfect. Can you give us a little bit of an idea on how you kind of assess for that, knowing that you don’t diagnose as a social worker?

Tara: Yeah, so I would ask the person if they had any other pre-existing diagnoses. And then I always do like a full intake session where I’m really getting to know the person, getting to know what they’re experiencing, their struggles. And then sometimes with autistic adults, it’s you’re doing more than one assessment session. But I’m just really looking to kind of categorize these different groupings of symptoms. So, though I can’t diagnose, I might be able to see, okay, this person is experiencing symptoms of generalized anxiety or symptoms of OCD or symptoms of, right? And so, I just have that very clear in my mind and that way I can structure the therapy moving forward and come up with a plan with them to make sure that we’re on the same page.

Tools, Resources and Strategies for working with Autistic Adults

Kayla: That makes complete sense. So, are there specific CBT tools, resources, or strategies that you’ve noticed that work best when working with autistic adults? And maybe even the opposite, are there any tools, resources, or strategies that you’ve noticed that aren’t as helpful?

Tara: So, from my perspective, I’m always adapting CBT for the person in front of me, right? Whether I’m working with an autistic person or a person who is not living with autism, like, I’m always adapting CBT because it’s person-centred. Not every tool is going to work for every person. So, starting from that perspective. But there are some adaptations that I do find tend to be helpful. And again, I can’t generalize because there’s this expression that’s like, you meet one autistic person, you’ve met one autistic person. So, keeping that in mind. But I do think overall, I have noticed that taking more time to get to know the person tends to be helpful. So, whereas like with the general population, I might do one or two assessment sessions it may take longer with an autistic person. And engaging them in their special interests, really getting to know what they’re passionate about and using that information to really understand how they navigate the world. I think keeping sessions structured, which is already a big part of CBT, so ensuring that the person knows what to expect can be really helpful. Using visuals is also very helpful for a lot of people. Concrete examples and again, linking those concrete examples to their special interests. And again, even with the general population, right, you’re looking to link these teachings, the information linked to psychotherapy with the person and how they make meaning in the world. So again, not so different.

I find with some people, especially if there’s a coexisting, co-occurring intellectual disability, having them reflect back what they’ve learned or what they’ve integrated throughout the session a little more frequently can be helpful. Adapting exposures to be more gentle. Explaining the goal of the exposure and allowing the person to decide whether or not they feel that they can or that they want to work on this. And again, you’re always getting consent to do exposures regardless, but being a little more intentional about being gentle about this and making sure that the person’s sensory needs are taken into consideration.

Being open to involving family and support is really important. Not everyone’s going to choose to do that, but sometimes it’s helpful to have a coach that’s really seeing that person day to day and that can really help. Integrate some of what you’re doing in the session.

And then sometimes the focus on behavior change versus cognitions can be helpful. So, it’s a little more concrete. And I want to be clear here. I’m not looking to, when I say behaviors, not looking to help that person change behavior that’s associated with the autism, right? It’s really looking at the behaviors that are more associated to those comorbid conditions and that the person feels they have control over, that the person wants to change. So, if they have a goal of– maybe they’re experiencing depression and this is linked to isolation and they have a goal of meeting some new people. And so the behavior change would be like, can you research some safe spaces where you feel comfortable in your city? So, we’re not looking to change autistic traits such as stimming. We’re really looking to make behavior changes that are associated to their goals

Kayla: I love that. And I think you provided some really great strategies. And something I’m really taking away, which I think as social workers and as therapists, we do this, but it’s really focusing on the person and the behavioral change, that’s the goal versus changing autistic symptoms or traits. Would that be an accurate reflection of what I’ve heard?

Tara: Yes, totally.

Considerations When Working with Autistic Adults

Kayla: Yeah, so when providing therapy to autistic adults, are there specific considerations that listeners should take into account when working with autistic adults?

Tara: Yeah, there’s a few things. So, I think it’s really important to make sure that we’re staying up-to-date with what the autistic community has to say, right? I think there’s been a really big shift throughout the pandemic in terms of the neurodiversity movement, we’re hearing a lot more autistic voices. And so, it’s really important to stay up-to-date on people’s perspectives, there’s various podcasts that autistic people are putting out there. And making sure that you are familiar with the social model of disability. So, it’s the idea that disability does not stem from the person, right? It stems from a society that is not built for a person. So, keeping that in mind and working from that perspective, especially when it comes to helping an autistic person challenge some problematic beliefs they might have about their autism. If you’re working from this social model of disability, you’re going to be able to help them integrate a much more positive view of what they’re experiencing.

Making sure that you’re familiar with ableism and the language that may stem from that is very important. If you have access to the person’s report regarding their autism diagnosis, I think that this can be really helpful because autism impacts each person in a different way, right? So, if you have this broken down and you can see exactly what they’ve scored on what assessment and the discussion around how this is impacting them in their life and then checking in with them to see if they agree with this assessment. And if they feel that it’s reflecting how they’re experiencing the world and how they’re experiencing their life. And how they feel that their autism is impacting them specifically.

So again, I think I’ve mentioned this, but really keeping in mind that you’re not looking to treat autism with CBT. You’re looking to treat the comorbid mental health conditions and then when it comes to supporting the autism piece, you’re looking to help this person achieve the goals they have within this society that’s not built for them. So, you’re helping them access accommodations. You’re helping them find safe spaces where they can unmask. Teaching self-compassion for those moments that are very, very difficult because of what they’re living. You might be helping them to prevent autistic burnout by reducing sensory input when possible. Or reducing particular stressors or reducing masking, right? So that’s how you’re using CBT to look at the autism, but you’re not looking to treat the autism.

Understanding that there’s a higher prevalence of the queer community within the autistic community. So just keeping that in mind. I think it’s like– I wouldn’t necessarily quote the statistic, but the most recent thing I saw was like you’re three times more likely to identify as queer if you have autism, if you’re autistic. So, keeping that in mind too, that there might be an overlap there.

And then the last thing I’m thinking of is just understanding pathological demand avoidance, which is also called pervasive drive for autonomy. This is not recognized by the DSM, but it’s definitely something that is recognized by a lot of autistic people and has been well documented. So, keeping that in mind. Yeah, I think that’s it.

Kayla: All of the information that you’re providing today is so valuable to our listeners because it’s really going to help support them and being able to support their clients who may have a diagnosis of autism.

Tara: Mm hmm. Totally. And that’s what I hope for.

When to Seek Consultation or Refer Out

Kayla: Yeah. So, when should a therapist seek consultation or refer out?

Tara: So, I really think this comes down to assessing your own competencies and your own capacities as you would for any other population or a mental health condition that you might be treating. So, most colleges, I know my college for social workers has guidelines to help us determine whether we feel that we’re competent in supporting a specific population. So, this is no different, right? Use that tool, really do a self-assessment. See how you’re feeling. Are you feeling comfortable?

I think that because there’s such a need for psychotherapists who are willing to work with autistic adults. A willingness, an openness, curiosity as well as some self-guided research is often enough. And I’ve heard autistic people say this, right? That my therapist had not worked with autistic adults before, but I just appreciated the openness because it’s sometimes very hard for clients to find a therapist and if they’ve built a relationship and then maybe they have a new diagnosis of autism they don’t want to necessarily be referred and have to start that process over again. So sometimes that is enough. And again, just assess your own feelings of competencies. Take into consideration what I’ve shared today. And then reach out for consultation, reach out for supervision. If you feel that there’s maybe some gaps in what you feel comfortable supporting.

Additional Insights

Kayla: Fabulous. So, do you have any additional advice or insights for listeners who might be working with or want to work with autistic adults?

Tara: Again, I really encourage you to do the research if this is sparking your curiosity. It’s really rewarding work because there’s such a lack of access. So not only are you getting to do the psychotherapy work that you love, but you’re really filling a gap in services, and that’s maybe my social worker in me is wanting to be able to do this work that’s lacking, right? Filling a need. So, I think if you have the interest, do your research, reach out and dive in.

Connecting or Referring to Tara

Kayla: So, Tara, are you accepting new clients into your practice? And if so, what is your private practice niche? Where do you currently practice and how could a listener reach out if they are seeking a referral for a client? And also, maybe even if they’re seeking support for a consultation.

Tara: Yeah. So, I do have a little bit of a wait right now, but generally accepting clients in the months to come. My private practice niche, so I work with three different populations, of course, autistic adults and neurodivergent, adults with intellectual disabilities, and usually it’s people who’ve had a really hard time finding the appropriate fit. So, they’ve maybe wanted to explore psychotherapy in the past, but they’ve never been able to find a psychotherapist who is the right fit for them. I also work with couples, and then I also work with young adults who consider themselves high-achievers, who are very anxious and kind of perfectionists and wanting to work through that. So those are my kind of three niches. Yeah, and in the future, I am going to be offering supervision, clinical supervision to social workers. So, you can keep an eye out for that also.

Kayla: And where do you practice? So, if a therapist is listening and they want to give a referral, which provinces are you registered or licensed in?

Tara: Yeah, so I practice virtually and in Ontario.

Kayla: Perfect. So, if you want to connect with Tara, check out her website at taramcraetherapy. com.

That’s taramcraetherapy.com

Or you can simply scroll down to the show notes and click on the link. Tara, thank you so much for joining us on the podcast today and providing us this roadmap with how to use CBT with autistic adults.


Tara: Thank you so much for having me. It was a pleasure to share this information, and I hope it sparked some curiosity in people who may be willing to open up their practices to autistic adults.

Kayla: Thank you, everyone, for tuning in to today’s episode, and I hope you join me again soon on the Designer Practice Podcast.

Until next time, bye for now.

Podcast Links

Tara’s Website: taramcraetherapy.com

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