Behavioral Therapy with an Individual with Asperger’s Disorder

| August 31, 2010 | 0 Comments

by Kelly Blankenship, DO, and Noha F. Minshawi, PhD
Dr. Blankenship is a developmental disabilities fellow, Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana; and Dr. Minshawi is Assistant Professor of Clinical Psychology in Clinical Psychiatry, Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana.

Psychiatry (Edgemont) 2010;7(8):38–41

Funding: There was no funding for the development and writing of this article.This article was supported in part by the Division of Disability and Rehabilitative Services, Indiana Family and Social Services Administration (Drs. Blankenship)

Financial disclosure: The authors have no conflicts of interest relevant to the content of this article.

Editor’s note: The cases presented herein are fictional and created solely for the purpose of illustrating practice points.

Key Words: Asperger’s disorder, autism spectrum disorder, psychotherapy, visual supports


Individuals with autism spectrum disorders have deficits in communication, social interactions, and emotional regulation and exhibit repetitive behaviors. These individuals can become very reactive to their environment and at times may engage in emotional outbursts. The social deficits seen in autism spectrum disorders are in part caused by the difficulty these individuals have with modulating their own anger and interpreting their own emotions and those of people around them. Individuals with autism spectrum disorders tend to learn and process visual information more effectively than auditory information. Thus, visual supports can help individuals with autism spectrum disorders process information more effectively. This article discusses the use of one particular visual support, an “emotions thermometer,” in helping instruct individuals with autism spectrum disorders on recognizing and modulating their own emotions. The article also discusses anger management techniques that can be utilized once individuals have begun to recognize more subtle signs of irritability within themselves.


Autism spectrum disorders (ASDs) are neuropsychiatric conditions that exhibit deficits in communication (i.e., delayed language development, echolalia, idiosyncratic language, difficulty maintaining conversation), deficits in social relatedness (i.e., minimal eye contact, lack of social and emotional reciprocity), and repetitive interests and activities (i.e., rocking, spinning, inflexible adherence to routine.)[1]

There are three ASDs—autistic disorder, Asperger’s disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS). Asperger’s disorder is defined by deficits in social interactions (failure to make appropriate peer relationships, difficulty with nonverbal communication) and restricted, repetitive, and stereotyped patterns of interests or activities. Individuals with Asperger’s disorder do not have a language delay or cognitive impairment.1 These individuals typically have high verbal intelligence and exhibit an expansive vocabulary at a young age. Although they are often very “book smart,” they have difficulty understanding nonverbal and reciprocal interactions and lack the ability to infer others’ mindsets.[2]

In addition, individuals with Asperger’s disorder often exhibit a very low frustration tolerance, an inability to modulate their own emotions, and difficulty interpreting the emotions of those around them. For neurotypical individuals, gestures, facial expression, voice tone, posture, and eye contact are all used to communicate the affect of the verbal content during communication. While individuals with Asperger’s disorder may correctly interpret one of these cues, they may have extreme difficulty when attempting to combine all of the cues to interpret the overall affective meaning of the communication.[3] Further, recent research has suggested that social initiation and social-emotional understanding is the major barrier in socialization for those with high-functioning ASDs.[4] They have the cognitive ability but lack the appropriate social skills to form and maintain age-appropriate friendships. These and other social deficits can often leave them isolated and/or rejected by their peers.[5]

Individuals with high-functioning ASDs also exhibit difficulty modulating their anger, which may lead to further difficulties in their social interactions. Because they have difficulty interpreting their own subtle changes in emotion, they are often only able to describe emotional extremes.

In addition to these difficulties, individuals with ASDs have trouble interpreting others’ emotions. They often need to be taught how to correctly identify their own emotions and those of other people. However, emotional understanding can be difficult to teach. In addition to this being a difficult subject matter on which to instruct, individuals with ASD often have a difficult time processing auditory-based information. Visual information is typically easier for individuals with ASDs to process. Individuals with ASDs often perform better on nonverbal tests of cognitive functioning.[6] Thus, when teaching individuals with ASDs, the use of visual supports (e.g., pictures, written symbols) can be very helpful.[7] Visual supports, such as the “emotional thermometer,” can help make abstract and difficult-to-understand topics (i.e., emotions) more concrete for individuals with ASDs.

This article describes an example of different psychotherapeutic exercises used to help an individual with Asperger’s disorder to develop the ability to recognize and interpret his or her own emotions and those of other people. Increasing the emotional understanding of individuals with Asperger’s disorder is of primary importance. Without appropriate understanding of the emotions of other people, individuals with Asperger’s disorder are at risk of further social withdrawal due to inappropriate expression of emotions and lack of responding to the emotions of others.

Case Example

Madison was a 45-year-old woman with Asperger’s disorder (composite case, not an actual patient). Although she had superior cognitive functioning (full-scale IQ above 150), her success in employment and relationships was always limited by her inability to regulate her own emotions and recognize other people’s emotions. Her low frustration tolerance resulted in rapid escalation to extreme anger without what most would consider provocation. She preferred a trial of behavioral therapy prior to initiating psychotropic medication.

Madison: I don’t have the normal range of emotions that other people have. I am either in a great mood or I am very angry. I can switch very rapidly between the two extremes. Most people can feel a little upset or a little happy. Those emotions don’t exist for me. When I get really angry I lose control; I scream and rant. People become afraid of me. I have ruined many relationships because I get so upset and can’t calm down.

Therapist: Everybody has a full range of emotions regardless of their diagnosis. We just need to teach you to identify the less intense moods. This way, before you become angry, we can identify techniques to use to calm yourself. This will keep you from becoming so upset that you feel you will lose control.

Practice point: Teach patients about levels of emotion

Individuals with ASDs commonly have a low frustration tolerance and significant irritability.[8] They may report that they alternate from calm to extreme anger very quickly. There have been several studies that suggest individuals with ASDs have difficulty understanding and interpreting their own emotions.[4] If they are not able to recognize less intense emotions in themselves, they will not be able to develop skills to help themselves calm down prior to “losing control.”

Knowledge of emotions often has to be explicitly taught to individuals with ASDs. Visual supports can help make abstract and difficult-to-understand topics (i.e., emotions) more concrete for individuals with ASDs. A visual support in the form of an emotion thermometer can be created to help the individual identify emotions between the extremes.[3] The emotion thermometer visual can take many different forms, e.g., drawing of a thermometer on a piece of paper with emotions listed in ascending order from happiness to anger. The thermometer should be created with the patient over the course of several sessions. The patient should choose the emotions that are placed on the thermometer with assistance from the therapist. On the emotion thermometer, the halfway point can be a neutral or “typical” emotion, such as “fine” or “content.” There can be 4 to 5 emotions below “content” on the thermometer visual that describe positive emotions in ascending order (e.g., proud, surprised, happy, elated). Then there should be 4 to 5 emotions above “content” that describe negative emotions in ascending order (e.g., upset, sad, frustrated, angry, livid). The visual concept represented by the thermometer is that as emotions become more negative, the mercury in the “thermometer” rises.

It may be helpful to start with only one side of the thermometer (negative or positive emotions). Giving the patient only one-half of an emotional spectrum on which to focus at a time may keep him or her from feeling overwhelmed. After he or she has mastered understanding and naming the emotions on one side of the thermometer then the other end can be addressed.

Once the emotions have been decided upon and placed appropriately on the thermometer, the next step is to build knowledge on what those emotion labels mean (i.e., what each emotion “looks like” and “feels like”). It is important to have the person define the emotions. If he or she is having trouble defining them, the individual can look them up in a dictionary, if necessary. The thermometer visual can then be utilized to help the individual identify his or her own emotional state.

Case Continued

Therapist: Over the next week pay attention to your emotions. Twice a day, try to identify when you are feeling one of the emotions on the thermometer. Keep a journal of the situation and emotion you felt. Also write down what your actions and thoughts were at that time.

Case (over the next few sessions):

Madison: I have been attending to my feelings and level of annoyances. I have been using the thermometer to rate them. I have kept a journal and now can tell that I have emotions that build up to being extremely angry. I also have been able to identify some of the triggers that can cause my level of frustration to increase. I just don’t know what to do when I start to become angry. I am not able to stop myself from becoming more and more upset.

Practice Point: Teach patients to identify and manage frustration

Irritability and low frustration tolerance are common interfering symptoms in individuals with ASDs. Individuals with ASDs also have deficits in theory of mind. That is, they often have difficulty interpreting a situation from another person’s point of view.[2] Thus, they see only their way of doing things as the correct way and often get angry when others have opposing views and ideas. Individuals with ASDs often become stressed by things that may not upset a neurotypical individual or their level of emotional response may seem exaggerated. Further, their inability to interpret their own emotions makes it difficult for them to leave a situation or find a solution prior to “blowing up.” Deficits in problem solving and social skills further complicate this issue, so even if they can identify that they are becoming upset, they have difficulty deciding how to handle it appropriately.[3]

There are multiple techniques that can be taught to help individuals with ASDs deal with stress and frustration. This article discusses several techniques that we used with this patient.

Case Continued

Therapist: Taking a break and removing yourself from situations can be a great way to calm down.

Madison: I have tried this before. I don’t find it helpful. When I leave the situation, I continue to ruminate about what was said and become more upset. I don’t find the breaks relaxing or helpful.

Therapist: You have to teach yourself to relax and enjoy breaks in a nonstressful situation first. Then, when you take a break after becoming upset, your body will know that it’s time to relax. First, you need to schedule breaks in your day when you are not angry or frustrated. Over the next week, decide on two times a day to take 15-minute breaks. During the breaks, engage in activities you find relaxing. It’s very important to schedule these breaks and take them every day.

Practice Point: Encourage patients to take scheduled breaks throughout the day

Rumination about prior events is common in individuals with ASDs. Many times, without training, removing themselves from situations and taking breaks are not helpful as they continue to think about the prior event and become more upset instead of calming down. Having them take scheduled breaks with planned activities is very helpful. Planned breaks allow for the pairing of relaxation with break times and, therefore, can assist in teaching the body to relax during these breaks. Planning breaks also gives them a plan to follow when they are upset and frustrated.[9]

Case Continued (several sessions later)

The patient had taken breaks with planned relaxing activities (e.g., reading and feeding her birds) twice per day. She was finding them helpful and was able to take a break when she became angry with her sister who came over to visit. However, she ran into another problem with this technique.

Madison: I was at work and became angry with my boss during a meeting. I couldn’t leave the meeting to take a break. I didn’t have a way to calm down in the meeting.

Therapist: This is very common. There are certain situations when it is very difficult to remove yourself. We need to find a technique that will help you relax in those situations. Have you tried deep breathing? This is done by taking a deep breath through your nose while counting to three, holding it for the count of three and letting it out through your mouth for the count of three.

Madison: I’ve tried this before; it doesn’t work.

Therapist: This is another skill that you have to teach your body how to use. At the beginning of each planned break try taking three of these breaths. Your body will learn to associate the deep breathing with a period of relaxation.

Practice Point: Teach patients deep breathing exercises

Deep breathing is a technique that many people find helpful to calm down. As we have already discussed, individuals with ASDs often are quicker to anger and have a very difficult time calming down. Thus, associating the deep breaths with a relaxing period of time (classic conditioning) can further reinforce the helpfulness of this technique.


As described above, individuals with ASDs need to be taught how to define their emotions. The strong visual processing skills often demonstrated by individuals with ASDs can be capitalized on to help with the process of understanding emotions. Using visual supports, such as the emotions thermometer illustrated in this case report, to teach these individuals how to recognize their emotions can be extremely helpful. In addition to difficulties with understanding emotions, individuals with ASDs may become angry quickly and may have difficulty calming themselves effectively.

They often need to be taught skills to cope with an increase in irritability once they have been able to identify these emotions. Teaching individuals with ASDs to practice relaxation skills during times of emotional calm first will allow them to better use these skills during times of heightened emotion. Improving emotional identification and coping in individuals with ASDs can help to improve social deficits, one of the core interfering symptoms of ASDs, while improving their overall quality of life.


This article was supported in part by the Division of Disability and Rehabilitative Services, Indiana Family and Social Services Administration (Drs. Blankenship). Thank you to Dr. Christopher McDougle, MD, for his review and comments.

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. American Psychiatric Association, Washington, D.C.;2000.
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3. Smith-Myles B. An overview of Asperger’s syndrome. In: Baker JE (ed). Social Skills Training For Children and Adolescents with Asperger’s Syndrome and Social- Communication Problems. Shawnee Mission, Kansas:Autism Asperger Publishing Co;2003:9–15;175.
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5. Tse J, Strulovtich J, Tagalakis V, Meng L, Fombonne E. Social skills training for adolescents with Asperger syndrome and high-functioning autism. J Autism Dev Disord. 2007;37:1960–1968.
6. Ganz J, Flores M. Effects of the use of visual strategies in play groups for children with autism spectrum disorders and their peers. J Autism Dev Disord. 2008;38:926–940.
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9. Baker J. Chapter 9. In: Baker JE (ed). Preparing for Life: The Complete Guide for Transitioning to Adulthood for those with Autism and Asperger’s Syndrome. Arlington, Texas: Future Horizons Inc;2005:112–135.

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Category: Past Articles, Pervasive Developmental Disorders, Psychiatry, Psychology, Psychotherapy Rounds, Quality of Life

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