From Conditioning to Compassion: Evolving Perspectives on Autism and Therapy
I wrote a bestselling book on Autism and Anxiety preaching the gospel of CBT. I now realize much of it was wrong.
I was wrong. Words that are always hard to say out loud but sometimes necessary.
I have written several published books on Autism related subjects over the years. The one that has sold the most copies by far is Asperger’s Syndrome and Anxiety, a book titled that way before Hans Asperger’s past was revealed. If I were to estimate its sales so far, I would guess it has sold around 30,000 copies. It’s also a book that, in part, hasn’t aged well regarding its content.
I was a green-behind-the-ears graduate student who had been diagnosed a few years earlier with autism. Receiving that diagnosis was the most self-revelatory event of my life by far. I was privileged enough to be able to receive a diagnosis because of parental support, something I didn’t even realize at the time was a privilege to begin with. But I intended to make the most of it.
This involved applying to grad school, getting the accommodations I needed to substitute my 2000 clinical hour requirement with additional classes, and knowing from the outset that I would not be obtaining licensure. I didn’t want to be a licensed psychologist — I knew that. But I did want that degree very desperately. Being an advocate and a professor were my goals in deciding to take the leap of faith by entering grad school. I knew my limitations all too well, realizing that sitting across the room from clients and engaging in psychotherapy with them was never going to be in the cards for me. Aside from my self-doubt, that would always be too emotionally draining.
I was never a good writer in school growing up. I have dysgraphia and was considered to also have a disability in written expression by all of my special education teachers in K-12. So, the idea of becoming a published author seemed comical at the time, given the internalized lack of self-confidence I had been fed a steady diet of from childhood onward about my writing. But back then, there wasn’t TikTok. No Instagram. The very beginning of blogging. Becoming a published author was the way to translate my ideas into the public sphere.
Asperger’s Syndrome and Anxiety was written at a time when I was both receiving therapy and learning about the process of how therapy worked. A specific modality of treatment, known as Cognitive Behavioral Therapy (CBT), has been all the rave since the 1950s when practitioners were starting to question the efficacy of psychoanalytic practice (think of sitting on a couch, talking about your earliest memories of your mother, and saying anything that comes to your mind, etc..that’s psychoanalysis in a nutshell). CBT’s rise happened because of the firm belief in its utility, empiricism, and measuring tangible external results, unlike psychoanalysis, which recommended that patients see their shrinks three or more times a week for it to work — with questionable scientific underpinnings to begin with.
Basically, the premise of CBT is that our thoughts are controllable. We can choose which to focus on and which we want to discard. It is said by those who promote CBT that if we control our thoughts, we can then change how we feel. And by changing how we feel, we can solve problems more effectively. And then, by changing how we solve problems more effectively, we can change how we act. And thus, by being in control, we can be less anxious.
I preached this philosophy heavily in Asperger’s Syndrome and Anxiety. Very heavily. To the point where I probably gave readers the impression that if you want to better your life and rid yourself of anxiety, you just have to reframe certain situations in your mind to more “accurate” representations of reality. Therapists refer to this as reframing cognitive distortions.
It is true that all people, not just autistic people, can sometimes have trouble being objective about themselves, and perhaps occasionally, we need to adjust our thoughts. Sometimes, we can be hard on ourselves, and we need to be told so by an outside party. Sometimes, we can think one person thought something awful about us, only to learn later on that our interpretation had no basis in reality. I do see some utility in CBT when it is self-empowering.
However, I overlooked significant problems with CBT when I wrote this book. For starters, personally, I wouldn’t say I like CBT. Funny, huh? Even though at the time I was writing this book, I was not a fan of CBT; I was academically convinced it was the best therapeutic modality for the autistic population based on the research. CBT has been used on me in therapy for years, and I have never liked it. The therapist utilizing the CBT is “always” right in their interpretations, and I, the client, am “treatment resistant” if I dare to question whether their cognitive reframes are actually true. Being a good little autistic soldier and wanting to be compliant, I would tell the good doctor that he was right, even though I might not believe this to be true.
For example, your therapist may tell you that you are using black-or-white thinking in a particular situation. This is one of the standard reframing techniques CBT practitioners use for both neurotypical and autistic people. Yet if your therapist knows autistic people can be inclined towards thinking in black and white terms, this can be inadvertently weaponized against you to sound something like…”Jim, you know you tend to think in black-or-white terms. This is another example.” But what if Jim happens to be right this time? Should he cede his judgment to his therapist?
Always remember this: The therapist making the “reframe” has an ego like everyone else. They may care about you and could be coming from a good place, but it may displease them to have their authority questioned. CBT only works when it works for you. It works if you can buy into the reframe after some reflection…but you have to buy into it; that’s the key. That’s self-empowerment. That’s genuine autonomy.
This power imbalance in CBT becomes even more problematic when we discover the interplay between Cognitive Behavioral Therapy and Applied Behavioral Analysis (ABA): Overlapping therapies that have been used on autistic populations over the years. It’s a fairly well-known fact in the autism community that the founder of ABA, Ivar Lovass, was not a real big fan of homosexuality. He weaponized behavior modification to “cure” gay people of their sexual orientation, which reparative therapists, a completely unethical form of therapy, would generously borrow from. He used the same techniques to reshape autistic behavior so that they would become “indistinguishable from their peers.” That particular phrase was written into many of my IEPs. Gee, I wonder why so many Autistic people mask?
So, an entire multibillion-dollar industry was built around doing just that — making autistics indistinguishable. As a preschooler, I was force-fed ABA even though I didn’t have a formal autism diagnosis (I was diagnosed with expressive and receptive aphasia). I remember being greatly scolded when stimming and greatly rewarded with marshmallows and being able to play with the jack-in-the-box toy for sitting still. Later on in life, I was also rewarded by my therapist for reframing my thoughts the way he wanted me to and critiqued by him when I failed to see things his way. My self-esteem became damaged the more I thought that my thinking process was somehow fundamentally flawed. The correlation here between ABA and CBT seems so apparent, and it was staring at me right in the eye, but I didn’t see it.
What CBT lacks is being holistic. As a matter of fact, any therapeutic modality used by itself lacks holism. If someone is using Rogerian therapy with me and tells me they would never know I am autistic by how I present, they would probably see that statement as an empathetic one. But I’ve never met an autistic person who takes that statement as a compliment. So misplaced empathy, while not as harmful as having one’s behavior go through a normalization process, is still sometimes not very helpful.
Many people have found Asperger’s Syndrome and Anxiety helpful, and I have certainly been highly grateful to anyone who has expressed this to me over the years. I certainly do not mean to remove what you gained from the book if this was true for a particular reader. But I have been rightly critiqued by fellow autistics for the one-sided approach that I took in writing this book. And I feel their criticisms are valid. If this article costs me some royalties on that particular book, I can live with that.
