Talking myself into and out of Asperger's Syndrome: Using Cognitive Analytic Therapy (CAT) to rethink normal

Victoria, 2015. Talking myself into and out of Asperger's Syndrome: Using Cognitive Analytic Therapy (CAT) to rethink normal. Reformulation, Summer, pp.18-22.

Note from the author:
Unlike many other contributors to this journal, I am writing this article about my experiences of CAT from the perspective of a client rather than a practitioner. I have no formal training in counselling psychology, therefore I may not always use the correct terminology and do not have a huge knowledge of research and theory to draw upon. However, I want to share my experiences with professionals, in the hope that you can link my practical experiences to the theory and use this to understand how to support many other individuals with Asperger’s Syndrome (AS). 

My background
Ever since a child I had always felt different, without ever being able to explain exactly why. I was physically healthy, I did well at school, my family was much like any other, I did the same things other children did, and yet I seemed to experience the world
in a totally different way. I felt that everybody else knew something that I hadn’t been told; everybody else had been given a copy of the rulebook and I hadn’t. Why did all the other girls seem to connect instinctively and know exactly how to talk to each other and become friends? Why were all my classmates able to get on with their families? Why was I always told that I was being selfi sh or inconsiderate, when I didn’t intend to be? Why did nobody else bat an eyelid when rules changed or situations were unfair? How could everybody else manage to sit in brightly lit, noisy rooms, wearing scratchy denim jeans and eating foods that I couldn’t even look at, let alone touch? What on Earth was wrong with me?

I went through most of my teens and twenties with these same thoughts. I learned some coping strategies over the years, I learned some things from trial and error, and some social skills I taught myself explicitly. I learned to avoid situations I couldn’t cope with. As soon I was old enough I moved constantly, from city to city, from country to country, from one job or course or idea to another, always thinking that things would be better somewhere else. I didn’t understand myself, had no self-esteem and never managed to connect with others.

Only in my late twenties, when working as a teacher of special needs, did I fi nd myself teaching pupils who were just like I had
been at their age. I began to read and research everything that I could about girls and women with Asperger’s Syndrome (AS), a term that had not existed when I was growing up. This was my ‘eureka’ moment. I liken it to reading a whodunit where you fi nd out on the very last page who did it; you then have to read the entire book again, interpreting every clue in a new light. I looked back on my life and it suddenly all made sense. This was why and how I was different.

Although I now had a reason, I didn’t yet have understanding. I was put on a long waiting list for a diagnosis of AS. In the meantime I felt a combination of hopefulness and hopelessness. Now that I knew what my difficulties were, I could surely begin to overcome them, but how?

How I learned about Cognitive Analytic Therapy (CAT)

My GP suggested counselling. I was sceptical, having had some counselling while at university and not having found it articularly beneficial. However, knowing now what the issue was, I realised I wanted the rest of my life to be different, so I agreed. After the first few sessions describing my difficulties and what I wanted from therapy, the therapist suggested Cognitive Analytic Therapy (CAT). I had never heard of it. I went away and researched it. In theory it all sounded useful enough. But there was one problem; it wasn’t the autism-specific answer I was looking for. Having realised my difficulties were due to Asperger’s (part of the autism spectrum), surely this was where the answers would lie? An internet search threw up no evidence for using CAT with people with autism. But, I told myself, maybe it would be useful nonetheless? And, anyway, there didn’t seem
to be much else out there.

Arguments for using Cognitive Analytic Therapy with clients with Asperger’s

I quickly changed my mind and began to see the advantages of CAT. There was something about this therapy that made sense to
me and best of all, it made sense of my Asperger’s. Personally, I got more out of the therapy than I had ever hoped for: not only a new understanding and awareness of myself and my relationships, but also practical strategies I could use every day, and a newfound confidence and self-esteem which allowed me to fulfil my potential for the first time in my life. It wasn’t long before I began to look at CAT from a professional point of view. Working on a daily basis with young people with autism I began to think; if the CAT approach worked so well with me, would it work so well with others with Asperger’s? And, are there specific elements of the CAT process which make the therapy so useful for this client group?

The rest of this article outlines my reasons for this argument:

CAT is highly structured and follows a predictable routine. CAT follows a structure which the client is told about from the very beginning: four sessions, a reformulation letter, twelve more sessions, goodbye letters, a follow up session. There are target
problems to be solved and rating scales to demonstrate progress.

The need for structure and predictability for people with Asperger’s is well-documented and helps to reduce anxiety. A
theory developed by Frith and Happe (1994) suggests that individuals with AS have a different system of information processing, often getting stuck on details rather than seeing the big picture or wider meaning. Therefore structure, routines and predictability can help to bring coherence to, and to make order out of, what is a confusing and incomprehensible neurotypical
world. As a client in CAT I could see clearly where the therapy was going and this element of security and predictability meant
that I felt confident and secure enough to open up and take risks. It also helped me to see the ‘bigger picture’, and to be able to put my current and past difficulties in a clear context, rather than getting ‘stuck’ on small issues as I had in the past.

CAT can be a highly visual therapy. Important parts of CAT are the visual diagrams and mapping out target problems on paper. A visual element can be incredibly useful to people with AS who often find visuals and diagrams help them see the links between things and understand how things work. Some people with AS also have associated language difficulties and so can draw in diagrams or pictures what they are unable to express in words. There has been signifi cant research suggesting that some people with Asperger’s Syndrome have a predominantly visual style of thinking (Attwood, 2007; Grandin, 1995) and further research shows that most people with AS have a limited vocabulary for feelings and emotions (Attwood, 2007). I
found that the visual aspect of the therapy was essential in helping me to put my journey into a meaningful story. Over the weeks, my diagrams turned from words and arrows into a representation of a tree surrounded by clouds, representing the new, solid foundation I was building, the branches that were growing and the old patterns of relating which may re-appear but did not have to be permanent, just like clouds.

CAT allows clients to get things down in writing. The reformulation and goodbye letters are written accounts of the therapy and
what you have shared with the therapist. I also found that keeping a journal throughout helped me to note down thoughts
and insights between sessions. Often, people with Asperger’s find it easier to understand and express themselves through
written communication rather than spoken, as spoken information requires so much extra processing of non-verbal clues. I found that having my ‘story’ down in writing certainly helped me to put things into context and enabled me to have a visual record of the changes that had occurred.

CAT is a social therapy, recognising the social origins of distress. CAT maps out early events, relationships and interpretations
of the world. People with AS typically have difficulties with social interaction, social communication and social imagination (Wing, 1981) which can cause difficulties in making and maintaining relationships with others as well as feelings of isolation and
being ‘different’. There can also be a social stigma attached to some AS traits (needing to be alone, obsessive interests etc). Therefore, CAT is particularly useful as it looks at the individual in the wider context that the individual has grown up in.

Relationships are the focus of CAT. CAT focuses on relationships, from relationships with early caregivers, followed by the
client’s relationships to others and themselves. CAT looks at patterns of relating and the effect these patterns have on our relationships and the way we are with ourselves. Hans Asperger originally recognised that the main difficulties of the syndrome later named after him are social relationships; ‘The nature of these children is revealed most clearly in their behaviour towards other people’. Tony Attwood (2007) also describes ‘the lack of social or emotional reciprocity and failure to develop peer relationships’ as being the key element of Asperger’s.

Therefore, investigating relationships can allow the individual with Asperger’s to investigate how they relate to others, which can be the root of many difficulties and low self-esteem. Lack of theory of mind and lack of empathy are two further difficulties often associated with Asperger’s.

I found that exploring how I perceived my relationships with others gave me a much greater insight into how I felt around
other people and where these feelings had originated. This new awareness helped me to understand that there were reasons for my feelings, thoughts and behaviours and that these actually made a lot of sense; I wasn’t such a bad person after all, my different way of interpreting the world had simply lead to me feeling different and having to find ways to cope with that.

CAT allows the client to build a trusting and honest relationship with the therapist. CAT is based on an open, honest and trusting relationship between the client and therapist. This has particular importance for people with AS who need honesty, openness and truthfulness. People with AS may struggle to understand other people’s intentions and need to be told explicitly what other people are thinking and feeling. Added to the fact that many people with AS take things literally and often remember
everything that is said, this can cause difficulties in real life. In CAT the therapist shares his / her thinking with you explicitly (ACAT) and reflects on what is happening.

Perhaps, however, more importantly, is the idea of ‘enactment’, that learned reciprocal roles will almost inevitably be experienced in the relationships between the client and therapist. The relationship can then model the new, healthier roles. Some people with AS will have had no experience of successful relationship building and will have never experienced an
empathetic, accepting, supportive relationship. The experience with the therapist can demonstrate how a trusting relationship can feel. For me, this was especially important. I experienced more positive ways of relating, had my attention drawn explicitly to these, realised I liked the way this felt, and wanted experience more of these with myself and with others.

CAT is about developing selfawareness and does not focus on labels or ‘diagnoses’. The therapy is about developing self-awareness and acceptance. The links between Asperger’s and self-esteem are well-documented (Attwood, 2007). Whether diagnosed or undiagnosed, the experience of growing up on a different wavelength can have a long-lasting impact. Simone (2010) suggests that women with Asperger’s can internalise guilt and blame from a very young age, as they can feel blamed for their erratic behaviour and social awkwardness. As women with AS can be average or above average intelligence and look ‘normal’ there can also be internal feelings of guilt – why can’t we just ‘get on with it’ and ‘deal with it’? (Simone, 2010). Other people, and society in general, may not be truly accepting of these differences. Therefore, a therapy which focuses on self-acceptance can be particularly useful for people with AS. This was another hugely important aspect of the therapy for me; suddenly, I realised that I did deserve to be successful, that I did deserve positive things. 

I had always believed that I just had to try harder and then I would be able to fi t in and do all the things other people do, then I would be just like others. But, through the CAT, my thinking changed; actually I realised I was far happier when I was being ‘me’. I had a choice: try to be neurotypical and never quite make it, or be ‘me’ and excel.

CAT is about developing more helpful patterns. Often people with AS can experience some infl exibility of thought, or ‘stuck’
thought patterns. However, CAT allows clients to experience new roles in a non-threatening atmosphere and refl ect on these.

It took me a long time to get out of old ways of thinking and I was very resistant to this change at fi rst. However, the diagrams, visuals and supportive atmosphere enabled me to connect with the ‘positive’ side of myself and break free from some of these thought patterns. The growing self-acceptance and self-esteem played a huge role in this, but also being taught ‘skills’ (mindfulness, journal keeping, practising new behaviours etc) gave me practical strategies I could use to continue to build this new-found psychological resilience.

In conclusion, there appear to be many aspects of CAT which make it a suitable therapy for use with people with AS, who
often experience depression, anxiety, social isolation, feeling of being different and a lack of self-esteem (NAS).

Final thoughts

A few months after fi nishing my course of CAT, I fi nally received my offi cial diagnosis of Asperger’s syndrome. Funnily enough, by that point it was almost unimportant to me. Through engaging with the CAT therapy I had gained an unforeseen amount of selfawareness and self-acceptance. I had learned to recognise my strengths, identify my barriers to success and had learned how to like myself and my Asperger traits. I had become more aware of my emotions and how I related to others. I had gone full circle: originally realising that I had a ‘label’ (AS) had empowered me, had brought me to therapy and enabled me to begin a journey of a lifetime, breaking free from limiting thought processes and negative beliefs. But, through engaging with
the therapy I found myself truly liberated; it no longer mattered what label anybody stuck on me, I was just quite happy being me.

ACAT, Association of Cognitive Analytic Therapy, ( Attwood, T., (2007), The Complete Guide to Asperger’s Syndrome. Jessica Kingsley Publishers: London. Frith and Happe, (1994), Autism: Beyond theory of mind, Cognition 50, 115-132.
Grandin, T., (1995), Thinking in pictures and other reports from my life with autism. New York: Doubleday. NAS, National Autism Society, ( Simone, R., (2010), Aspergirls: Empowering females with Asperger Syndrome. USA: Jessica Kingsley Publishing.

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Full Reference

Victoria, 2015. Talking myself into and out of Asperger's Syndrome: Using Cognitive Analytic Therapy (CAT) to rethink normal. Reformulation, Summer, pp.18-22.

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