Tips for counseling individuals with high functioning Autism Spectrum Disorder, also known as Asperger's.

1. Counseling College Students
with
Autism Spectrum Disorder
David Zehrung, Ph.D.
dzehr1@gmail.com
August 26, 2016

2. They are strangely impenetrable and difficult to fathom.
Their emotional life remains a closed book.
– Hans Asperger

3. Bad news: ASD is an enduring way of
perceiving, processing, and interacting with the
world.
Good news: Learning can happen. It’s more
about skills to compensate or work around
differences.

4. This presentation consists of responses to questions
submitted by college counselors.

5. •When is it appropriate to broach the subject of autism
spectrum disorder (ASD) with a student who may not be
aware that they fit some criteria for autism? And if so,
how do you suggest that be done?
Often after rapport has developed, “I was reading/
thinking about something the other day, and I
thought of you. I’d like to get your thoughts to see if
some of these fit your experience:” (paraphrase
criteria for Asperger’s or Autism Spectrum Disorder).
If they endorse a good many of the symptoms,
mention Asperger’s or ASD, holding it loosely.
Perhaps encourage them to read some on it to see if it
fits.

6. When is it appropriate to broach the subject of autism spectrum
disorder (ASD) with a student who may not be aware that they fit some
criteria for autism? And if so, how do you suggest that be done? (cont.)
If the referral is Narcissistic Personality Disorder or
Bipolar disorder, perhaps sooner, since they are
grappling with serious diagnoses anyway.

7. How difficult is it typically to get a client with ASD
to become more aware of thoughts and behaviors
that are not working well for them? (CBT?)
Varies with severity.
Insights may not stick.
With mild to moderate severity of inflexible thinking, CBT can be helpful.
Being data/evidence driven, CBT may be more helpful than insight-
oriented approaches.
Reality Therapy (William Glaser) and Motivational Interviewing might
similarly be useful. A commonality might be to start with the pain-point,
or distressing situation/outcome, and work backward to the unhelpful
behaviors and thoughts.

8. How difficult is it typically to get a client with ASD
to become more aware of thoughts and behaviors
that are not working well for them? (CBT?)(cont.)
It may be useful to use a CBT form, e.g., from Mind Over Mood - to
visually bring their thinking into more balance, to more fully account for
situations.
As examples, you can use seeing a dog running toward you, or seeing a
car pulling out in front of you. There’s your initial response, but there
may be more to the situation.
You can use examples of competing rules/virtues in social behavior,
computer programming, etc.
You can use examples of the effect of missing variables on engineering
outcomes as well as social situations.

9. How can I get a client with ASD to
communicate and understand feelings and
emotions better?
Ah, this is the crux of the biscuit!
Empathy training can help with understanding the
feelings and emotions of others, as well as one’s own:

10. How can I get a client with ASD to
communicate and understand feelings and
emotions better? (cont.)
Tailor training to their major. E.g., for business majors, you might try something like:
https://www.mindtools.com/pages/article/EmpathyatWork.htm
http://www.bbc.com/news/magazine-33287727 has some ideas. One that intrigues
me is “borrowing a person for conversation.” Teaching & role-playing would be
needed so the client is the “interested inquirer” vs. the interrogator.
https://www.questionwritertracker.com/quiz/61/Z4MK3TKB.html can be a skill
assessor/developer.
This interactive ‘book’ can help with learning to read facial expressions: https://
itunes.apple.com/gb/book/emotions-reader/id840124106?mt=11&ign-mpt=uo%3D4
Role-playing will be necessary to calibrate how and how much to communicate - can
use circles of closeness as a guide.

11. What obstacles do counselors working
with clients with ASD typically face?
Statements that come across as rude about the therapist or
others.
More dichotomous, black & white thinking than some other
populations.
Detail-oriented attention, including visual attention. E.g., eye
contact is usually poor, but they may keep looking at details
of our body. Sometimes that detail can hold sexual interest.
Often they are still listening, however. In fact, they may find it
easier to attend to what you are saying if they avert their eyes.

12. What obstacles do counselors working with
clients with ASD typically face? (cont.)
Relationship with support staff may be strained. E.g.,
overly commenting on staff errors, personal space
issues, blunt or demanding phone calls, etc.
Violations of social mores, e.g. Speedos example.
Maintaining focus on topics that are not part of their
special interest.

13. How prevalent are anxiety and depression
issues among those with ASD?

14. How prevalent are anxiety and depression
issues among those with ASD?
“Depression . . . is the most common co-occurring disorder in ASDs, with prevalence rates ranging from 5
to 82%.”(Ghaziuddin, 2005; Shtayermman, 2007)
Anxiety disorders have been reported in approximately 35% of individuals (Green, Gilchrist, Burton, &
Cox, 2000; Kim, Szatmari, Bryson, Streiner, & Wilson, 2000; Leyfer et al., 2006)
lab Children & adolescents: 30% clinically depressed, 35% clinically anxious http://www.ncbi.nlm.nih.gov/
pmc/articles/PMC3355529/
70% had experienced at least one episode of major depression, and 50% had suffered from recurrent
depressive episodes. Anxiety disorders were seen in about 50%. http://www.sciencedirect.com/science/
article/pii/S0891422211001442
Rates of mood and anxiety disorders were 35 and 77%, respectively. http://onlinelibrary.wiley.com/doi/
10.1002/aur.23/full
The ‘Extraversion’, ‘Agreeableness’, and ‘Conscientiousness’ scores of the NEO-FFI were significantly lower
in adults with AS than in controls, and ‘Neuroticism’ was higher in this Japanese study. http://
www.sciencedirect.com/science/article/pii/S1750946711000389

15. Are problems such as anxiety and
depression difficult to spot because
communication of emotions may be limited?
They can be, since nonverbals are different, not just verbal
communication. In nonverbals, look for changes in motor activity
(agitation, increased stimming, sullen staring at a spot in space)
Checking in each session with “how’s your mood been since our last visit”
can be helpful, instead of the more general “How’ve you been?”
Also, you can directly ask about current emotions (could be part of a
mindfulness exercise, where they check in with their emotions, body, etc.).
One approach would be to use questionnaires. There are problems with
ASD and self-report questionnaires, but endorsement of clinical
symptoms on questionnaires is high in ASD.

16. Do you have advice on a support group for
those with ASD? Could this be a good way for
a client with ASD to combat social isolation?
2014 - A Mindfulness-based group intervention improved psychological and
somatic symptoms. Improvement was maintained for 9 weeks. http://
www.mindfulnessbijautisme.nl/
L_termijn%20effect%20mindfulness%20032014.pdf
2013 - A group-based Mindfulness intervention reduced anxiety, depression and
rumination. Positive affect also increased. http://autismandmindfulness.org/
Mindful_spek%20et%20al%20RIDD1640.pdf. The autismandmindfulness.org
website says an English translation of their workbook is coming out.
2011 - Outcome study showing benefit from a group intervention based on the
Aspirations model: https://www.researchgate.net/publication/
225140378_Social_and_Vocational_Skills_Training_Reduces_Self-
reported_Anxiety_and_Depression_Among_Young_Adults_on_the_Autism_Spe
ctrum

17. Do you have advice on a support group for those
with ASD? Could this be a good way for a client
with ASD to combat social isolation? (cont.)
2007 - This is the Aspirations group program discussed in the
outcome study on the prior slide. https://www.researchgate.net/
publication/
230853073_Outcomes_of_a_Social_and_Vocational_Skills_Suppor
t_Group_for_Adolescents_and_Young_Adults_on_the_Autism_Spe
ctrum
2010 - This small study used Mind Over Mood in a group setting, and
found benefit. I requested the article but haven’t received it yet:
https://www.researchgate.net/publication/
46182215_Group_Cognitive_Behaviour_Therapy_for_Adults_with_
Asperger_Syndrome_and_Anxiety_or_Mood_Disorder_A_Case_Ser
ies

18. Can empathy typically be taught to someone who
has ASD? Would role-playing possibilities of
others' perceptions and emotions help with this?
While our interventions do not cure the underlying neurological differences,
skills training can help increase social success.
Twist on Golden Rule - Treat others as we wish to be treated — We wish to be
treated according to our sensibilities. Others wish to be treated according to
their sensibilities.
This program can help with reading nonverbal cues: https://
www.amazon.com/Mind-Reading-Interactive-Guide-Emotions/dp/1843102153
This covers more ground than just empathy, but includes ideas for social
perception and relationship skills. The author, Nowicki, also authored a book
below. https://www.amazon.com/Master-Tools-Adult-Social-Relationships/
dp/156145558X/ref=sr_1_1?s=books&ie=UTF8&qid=1471555636&sr=1-1

19. Can empathy typically be taught to someone who
has ASD? Would role-playing possibilities of others'
perceptions and emotions help with this? (cont.)
Nowicki’s other book, helps develop discernment of nonverbal cues.
https://www.amazon.com/Will-Ever-Fit-Breakthrough-Conquering/
dp/0743202597/ref=pd_sim_14_4?
ie=UTF8&psc=1&refRID=V5FZ0RGJQ51K4EER5R1X
This program is probably NOT a good fit for ASD, overall, but it might
provide some ideas that could be adapted. See url or included .pdf.
http://cultureofempathy.com/References/Experts/Others/Files/
Marieke-Kingma-Empathy-Training-Manual.pdf
This is for men with Asperger’s, but do you see any difficulties in this
list? http://www.adultaspergerschat.com/2011/05/30-relationship-
tips-for-aspergers-men.html

20. What are some techniques we can use to
help create more flexibility in rigid thinking?
Social stories or repeated practice/discussions about
probabilities vs. laws/guarantees. Can use sports
analogies, chaos theory, etc.
See CBT and general psychotherapy resources below.

21. What can we do to use more visual
techniques in our talk-therapy to help clients
with ASD understand concepts better?
See Attwood, under general psychotherapy resources.
Tailor to interests. E.g., for electrical engineers, software coders,
mathematicians or social science researchers, use schematics or flowcharts,
including balloons for unknown moderating variables (e.g., variables
important to others in relationships). For animation/video-oriented folks, use
story-boarding to help with sequencing and identifying gaps in social events,
and to develop alternate endings.
See Nowicki, above. Start with analyzing a painting. Move to silent video.
Goals are to identify emotions based on nonverbal information, but also to
discern cause and effect, or sequence in social narrative. Content could be
selected based on the current therapy theme/topic. E.g., dating relationship,
or job stress.

22. What can we do to use more visual techniques
in our talk-therapy to help clients with ASD
understand concepts better? (cont.)
Valerie Gaus: thought chain - bubbles, fleshing out
thoughts between antecedent and consequence.
During sessions move pebbles, avatars, or other
objects representing therapist and client closer or
further away, as a visual cue/meta comment about
how things are going in the session, then debrief/
discuss. Both therapist and client has access to these.

23. CBT TIPS & RESOURCES
2012 - article from Kennedy Krieger, reporting CBT can be effective in ASD.
One study with children found the only area of difficulty was in recognizing
emotions. They went on to say: “In addition, traditional CBT tends to require
strong linguistic and abstract thinking abilities, and these can be a challenge
for individuals on the autism spectrum. Realizing this, researchers have
worked to develop modifications to CBT that render it more ASD-friendly,
such as making it more repetitive, as well as visual and concrete.” https://
iancommunity.org/cs/simons_simplex_community/
cognitive_behavioral_therapy
Valerie Gaus - CBT for Adult Asperger Syndrome. See the included slide deck
on this topic from Dr. Gaus. Also, her book: https://www.amazon.com/
Cognitive-Behavioral-Asperger-Syndrome-Indivdualized-Treatment/dp/
1593854978/ref=sr_1_2?s=books&ie=UTF8&qid=1471551933&sr=1-2

24. General Psychotherapy tips &
Resources
The Complete Guide to Asperger’s, by Tony Attwood - See
included .pdf of this book, especially Chapter 14. https://
books.google.com/books?
id=ZwQGsuCNMPYC&pg=PA316&lpg=PA316&dq=aspergers+ps
ychotherapy+adult&source=bl&ots=7r8IA9yht8&sig=c2KtYJCOJ
rStdpT_IgLfEESgO4o&hl=en&sa=X&ved=0ahUKEwiC_J63jcvO
AhXCGR4KHePZDQc4ChDoAQhWMAk#v=onepage&q=asperge
rs%20psychotherapy%20adult&f=false
Rapport is essential, “but clients with Asperger’s can either
instantly, and permanently, like or dislike other people, especially
professionals.” p 318

25. General Psychotherapy tips &
Resources (cont.)
This client may “require more time to cognitively process
explanations, and will benefit from a clear, structured and
systematic approach with shorter but more frequent therapy
sessions. It will also help to have the main points from each
session typed and made available to the client and to review
those points at the beginning of the next session.” p 318
“Liane Holliday Willey explains that ‘Self-analysis does not
come easy to the aspie, particularly the male aspie. Some of
us never get to the point where we can look inward and
explain outward.’” p 318

26. General Psychotherapy tips &
Resources (cont.)
“The person with Asperger’s syndrome can be very self-critical, one of
the contributory factors to a clinical depression. Caroline, a teenager
with Asperger’s syndrome said to me that ‘The worst thing about
disappointing yourself is that you never forgive yourself fully.’
Psychotherapy can help reduce the self-doubt and self-criticism.” p
320
“The client with Asperger’s syndrome can be more relaxed and able to
provide greater insight into inner thoughts and experiences by being
asked to engage in a therapeutic ‘conversation’ using two connected
computers, exchanging e-mails or drawing events as a Comic Strip
Conversation.” p 326 Attwood goes into detail about these throughout
his book. Just use Comic Strip as a search term in the .pdf.

27. General Psychotherapy tips &
Resources (cont.)
“The psychotherapist may not be able to use transference constructively as
with other clients, but can become a mentor, someone who understands
and provides education, enabling the person with Asperger’s syndrome to
articulate his or her perspective and intentions better.” p. 325-326
“The altruistic desire to please people can be less of a motivation for
children with Asperger’s syndrome. I usually prefer to appeal to the
intellectual vanity of such children, and commend the child for his or her
intelligence, how smart he or she is, rather than commenting on how
pleased I am.” p 324
The Emotional Toolbox article, by Attwood, discusses a number of social
and emotion regulation tools for ASD. See included .pdf.

28. General Psychotherapy tips &
Resources (cont.)
Ramsay 2005 — See included .pdf of this article. “These patients are more likely to derive
benefit from therapists who are active in session and give directions, suggestions, and
information, than from therapists who rely on reflection, emotional encouragement, and the
notion that patients must discover their own answers to their problems. Said differently, AS
adults are in need of therapists who help make visible what had previously been invisible in
social situations.”
“Nondirective, exploratory treatments without specific behavioral goals that have relevance for a
patient’s daily functioning will likely result in the patient becoming frustrated and withdrawn,
and the therapist feeling ineffective.”
“Inviting a significant other familiar with the patient to early sessions helps the therapist get third
party information about the patient’s functioning.”
“Motivational interviewing techniques (Miller & Rollnick, 1991) that include a discussion of
a patient’s motivation for engaging in social interactions and that highlight areas of
dissatisfaction for the patient are helpful in eliciting workable treatment goals that are
relevant for the patient.”

29. General Psychotherapy tips &
Resources (cont.)
TIP: don’t be Aspie-centric. Be person-centered.
Asperger’s may be an adjective that capture various
characteristics about them. Self-identifying with
Asperger’s can be healthy, but over-identifying as
Aspie can have downsides, too.

30. General Psychotherapy tips &
Resources (cont.)
Paula Jacobsen - more of a psychoanalytic approach, primarily about
children. https://www.amazon.com/Asperger-Syndrome-
Psychotherapy-Understanding-Perspectives/dp/1843107430/
ref=sr_1_1?
ie=UTF8&qid=1471531487&sr=8-1&keywords=Asperger+Syndrome+
and+Psychotherapy+Understanding+Asperger+Perspectives+Paula+
Jacobsen
This article doesn’t give new information, but it’s an example of
therapy information an ASD person might find online: http://
www.adultaspergerschat.com/2011/10/counseling-aspergers-adults-
musings.html

31. Social Resources
A board-game coffee house in Mechanicsburg.
http://www.gametablecafe.com/
Social groups regarding Asperger’s: http://
www.meetup.com/topics/asperger-syndrome/

32. Apps & Other Resources
Best apps for college students with Autism — http://
cipworldwide.org/articles/12-best-apps-for-college-
students-with-autism/
Apps for Adult Aspies — https://www.reddit.com/r/
aspergers/comments/2rq0eo/apps_for_adult_aspies/
http://www.adultaspergerschat.com/
https://www.reddit.com/r/aspergers

33. Living Well & Stress Management
Valerie Gaus book for adult Asperger’s individuals. https://www.amazon.com/
Living-Well-Spectrum-Challenges-High-Functioning/dp/1606236342/ref=sr_1_1?
s=books&ie=UTF8&qid=1471551910&sr=1-1
Super Better, developed by a female gamer who went through depression after a
concussion. Research-based, and a University of Pennsylvania study found
benefits: https://www.superbetter.com/
Heart rate monitor apps (there’s a bunch) for monitoring heart rate before
relaxation strategies and after.
Diaphragmatic breathing apps (there’s a bunch) to help with focusing on the
process. A free one developed by the Department of Defense for soldiers is Tactical
Breather. It has voice directions you can turn on or off, and visual cues. http://
t2health.dcoe.mil/apps/tactical-breather

34. Random Info
Many ASD folks are gamers. The Guild web-series has a cult following, and illustrates
humor and pathos among gamers. The series opens with our heroine being fired by her
therapist: http://watchtheguild.com/ — season 1 trailer https://www.youtube.com/
watch?v=zYLOIMoSFv4
Some ASD folks like Autonomous Sensory Meridian Response (ASMR) sensory input:
https://en.wikipedia.org/wiki/Autonomous_sensory_meridian_response
ASMR on YouTube: https://www.youtube.com/results?search_query=asmr
Washing machine with 300,000 views… https://www.youtube.com/watch?
v=hTz_mS7kb2A
Information regarding facilitating the transition between high school and college - see
included slide decks, plus: http://secondarytransition.org/