The only way to overcome anxiety is through exposure

[Passaggressfedup]

I recently overcome a massive anxiety of mine. I feel so liberated and proud. It has made me think of the other significant anxiety triggers I experienced in life and concluded that all have been overcome through regular, controlled exposure over time.

I read so many thread about children or young people experiencing anxiety, where the parent has opted to take the child away from the situation thinking it is what's best for them.

I appreciate that there was some specific instances where removal is the for the best, but aren't we, as a society, making things worse by not helping our children to face their fear so that they can not only gradually get over that particular fear, but also learn to build that sense of resilience, pride and positivity that comes with it?

The reasons why CBT often doesn’t work for those with autism are as follows;-

Key reasons why standard CBT is challenging for autistic people include:

1. Differences in Thought Processing and Communication

Alexithymia and Interoception: Around 50% of autistic adults experience alexithymia, making it hard to identify, name, and report emotions, which is foundational to CBT. Weak interoception (sensing one's own body) means an autistic person might not feel anxiety until they are already in a state of crisis or meltdown. Literal Interpretation: Autistic people often process information literally, making the metaphors, abstract, and hypothetical questions common in traditional therapy hard to understand. Bottom-Up Processing: Autistic brains focus on details first to build a picture (bottom-up), while CBT often requires starting with a big picture concept or feeling and breaking it down (top-down).

1. Misinterpretation of Sensory and Physical Realities

Sensory Trauma vs. Irrational Fears: CBT focuses on changing thoughts about irrational fears. However, anxiety in autism is frequently triggered by sensory overload (sounds, lights), which is a physiological trauma response, not an irrational thought that can be rephrased. Meltdowns are not "Behavior": A therapist may mistakenly treat a sensory-driven meltdown or shutdown as a voluntary behavior to be corrected, rather than a trauma response to an unsuitable environment.

1. Misalignment with Autistic Cognitive Style

Cognitive Rigidity and Perfectionism: Autistic thinking often involves a high need for structure, routine, and a black-and-white (binary) perspective. Difficulty in changing these entrenched thought patterns can cause resistance in therapy. Masking and Burnout: CBT can sometimes inadvertently teach autistic individuals to mask or suppress their differences, requiring them to "shape-shift" to fit neurotypical standards, which leads to increased anxiety and burnout. Monotropism: Autistic people tend to be monotropic, meaning they focus intensely on a limited number of interests. Constant shifting of focus to different life topics, common in traditional therapy, can be exhausting and unproductive.

1. Environmental and Social Barriers

Unsuitable Therapy Setting: Conventional 50-minute, face-to-face sessions with high social demands (eye contact, small talk) are exhausting for autistic people. Lack of Specialized Training: Many therapists lack training in autism, leading them to use standard, neuro-exclusive practices rather than tailoring their approach.

The last is key. The lack of reasonable adjustments and expertise across the NHS for anything let alone CBT is frankly appalling
and a reality. Hence CBT being unlikely to work in it’s state as a mop up everything, one size fits all 6 week online course directed from a GP.

My dc have had other far more useful treatments and therapies.

My dc have achieved huge things without the head on approach which is so damaging for many.I’ll wager many struggling with far more than shyness achieve more without meeting difficulties head on. Avoiding and staggering difficulties has helped my dd to achieve. Meeting difficulties head on made her ill and her difficulties far worse.

Who says conditions shouldn’t be pathologised?Pathologising has got my kids treatment adjusted and lead to the right treatment they need.

Well thanks Chat GPT for that. Nonetheless I did post you a peer reviewed research paper which concludes that CBT certainly can be effective for people with ASD. It does require adjustments and therapists in our trust have received training.

Financial constraints are what they are. Is it not obvious that there is a trade off and you cannot have a hugely specialist tailored therapy available promptly for free to all as it is unaffordable and will not be necessary for everyone? A stepped care model is in place where the easier cheaper things are tried first because that’s what is affordable. I am old enough to have worked pre IAPT and before there was self referral for short courses of CBT there was nothing at all except a 5 year waiting list. The NHS is doing what it can with the resource constraints that exist and it’s better than nothing.

What alternative therapy modalities have your DC benefited from and how did they access those as that would seem to be more constructive to discuss than just complaining about CBT and graded exposure and suggesting it’s harmful which will put people off seeking care and keep them
stuck.

It does not work for all ND people
even with adjustments and training as I’ve been told by quite knowledgeable professionals. Forcing CBT when it is inappropriate and not even adjusted or by a properly trained professional as regards autism can be hugely damaging. Also the training NHS therapists receive re autism is woefully lacking. The ignorance we repeatedly come across from supposed trained professionals is shocking.

So we are where we are. CBT is often inappropriate for those with autism and anxiety in autism is often nothing like that experienced in NT people. it’s far harder to treat even before it gets left to get a whole lot worse often with additional conditions such as CPTSD in the mix.

I agree with this and see it mirrored in my private work.
A large percentage are “failed by camhs” (their own words) or “didn’t like, couldn’t do CBT” (also their own words). Not only does it often not work, it often makes problems bigger and harder to turn around. I get why the NHS use it. They can promote six or ten session models and leave the client feeling that they just didn’t try hard enough when it’s barely touched the sides of their issues.
In reality, therapy takes as long as it takes and sometimes that’s short term, more often it’s long term.

just anxiety?
Was he assessed for ASD?
This sounds like a classic ND presentation.
I assume you think he was trying it on or his parents were pandering to him?
I understand that students like this can cause issues for teachers who just want students to shut up and sit down so they can teach. I’ve come across many teachers like you in my career, sadly.

Which is jolly convenient for someone making a living out of it I guess….

Many private therapists work in the NHS too or have done. I’ve heard of so many leaving the NHS for private because they’re so disillusioned.

Frankly thank goodness for private practitioners as you are highly unlikely to get anything off the NHs until you’re beyond crisis point and they want to then keep you out of inpatient.

I adhere to the ethical framework of my professional association and would never attempt to hold on to a client who is ready to pause sessions. It’s quite insulting that you’d suggest I do!

yes, this is me! Benefits to NHS work include all the usual public sector benefits. In the end though, the negatives outweighed the positives and I couldn’t work ethically in the way I want to. Many others have left too.

I pay for private therapy. To be honest 6 sessions from the nhs didn’t even touch the sides and wasn’t helpful.

Yes it helps, IF it is led by the person experiencing the anxiety and is at their pace. I think school is a pretty bad example, if someone is being bullied, feeling a failure because they can't keep up with work and experiencing sensory sensitivity, forcing them to go all day every day could be counterproductive.

I think as long as it’s done gently, then maybe. I was forced to do something everyday in my previous career that made me so anxious I became ill and has left me pretty traumatised so I’m not sure it works all the time.

I guess this is a part of the problem for the NHS.
Estimated cost per session for the NHS is £124 (govt figures) so that £744 for one individual for 6 treatments that you say weren’t helpful.
What do the therapists on this thread suggest should be the approach? obviously open ended therapy on the NHS is a huge investment (and also risks being a pure waste of money?). And private therapy is too expensive for many.

I'll get flamed here right? But i'll say it because I'm not the only one thinking it.

Im starting to think all this sort of narrative, with the overly academic scientific vocabulary.....

It's actually quite a lot of bollocks really. Excessive navel gazing, overly self involved, too introspective to be useful.

Everyone can learn/change. Everyone. Autistic people might find some things harder. They might really not like some stuff. But with repetition everyone can learn and adapt to some degree.

Sometimes to get better we have to do things that are:

• hard
• uncomfortable
• upsetting

A bit like physio after a serious physical accident. It can be really really hard but if we don't soldier through, we can lose the mobility.

What do you suggest for me?

She didnt say autistic people cant change. She said techniques other than cbt have been more useful and gave some examples of why cbt can be less succesful for some people with autism.

I have a child with autism who previously had severe anxiety. His anxiety was treated without cbt or exposure therapy. So i feel like I have a lot to say on the topic that could be useful around techniques that do work...

However I agree with the first person's view that cbt does work for some autistic people and they should be put off trying it just because it doesnt work for everyone.

I agree to an extent, but it depends on the situation.

When DS started to be unable to attend school - mix of ASD, lockdown, switching from Infants to Juniors, bullying - we pushed him, the school pushed him, and it backfired hugely to the point that for a while he was only able leave the house after dark. A note delivered from a girl in his class saying he was missed led to a massive meltdown.

This wasn't fixable by pushing through, because pushing through would still have meant being with children who had bullied him for being weird, which increased his 'weird' behaviours (stimming etc.) to the point of them being disruptive to the class, and children, particularly the bullies would not have let that go. Pushing through would have been damaging.

For me pushing through my anxiety about flying and getting on a plane has left me never wanting to get on another one ever again, while my post lockdown anxiety about using public transport has been successfully pushed through.

It really isn’t bollocks that’s hugely abelist! It isn’t navel gazing either it’s huge difficulties due to a disability .

Do tell me how somebody with Alexithymia and all the other difficulties autism brings can just do CBT, it just isn’t relevant for many and there is no repetition on the NHS let alone autism informed adjusted care.

This thread is about exposure being the only answer. It isn’t. Many people autistic or otherwise learn to mange anxiety without exposure.

My dc do hard, upsetting and uncomfortable things all day every day. Hence their NDs being classed as disabilities. Like most ND people they are more resilient and tougher than anybody I know.

I’m sorry to read that. With mine it’s worked well - they both tackled things they weren’t initially keen on and have stuck at things, but I hope I would have been flexible enough to change approach if it wasn’t helping.

The NHS are utterly wedded to CBT, which has been so diluted in practice it’s bears little resemblance to the evidence based practice research indicates as effective.

Therapy doesn’t need to be open ended, agreeing say 12 sessions with a clinical review and the possibility of extending would be a good start, as would being open to offering other, relational, models. Not offering CBT for trauma would be another help - offering therapy following Herman’s 3 stage model with the same therapist where that is indicated (eg for complex trauma) instead of the bastardised model on offer under the guise of trauma therapy. Having a decent clinical assessment for readiness and suitability for therapy would also help.

Understanding therapy as a relational process whatever the modality, instead of a tick box treatment would be a very good start.

I think there's a fair balance. The current issue is that the easy things to try, which may well be suitable for a proportion of young people if offered promptly, aren't accessible until it becomes unsuitable.

I fought to get DD2 seen by CAMHS and her referrals, made by GPs, School SENCO, and a specialist SALT, were closed, I think, 4 times. Might have been 5. Finally, someone phoned me and said 'I'm meant to be closing this referral but it just seems like we're missing something here.' They accepted the referral, and then she was offered Single Session Family Therapy. I had to point out that our family makeup made this inappropriate (older sibling with SEN would have dominated the session because she wouldn't have coped). So we had to travel over 20 miles for an individual Single Session Family Therapy appointment, without family. Then the therapist wanted DD2, who by then was in a special school because of her needs, to do an online group therapy course. Once she saw us, it was obvious to her that DD2 wouldn't manage that, so she decided to close the referral at that point because DD2 has ASD. I had to get very assertive, pointing out that I had jumped through all of their hoops, and needed to know at what point somebody would take responsibility for deciding if she needed the medication that the GP and the SALT had both said was vital to making progress. Finally, she was put on the psychiatry waiting list.

In the meantime, DD2 had weekly SALT sessions that were essentially CBA (CBT adapted for ASD). Initially working on helping DD2 to recognise when she was anxious, then to try to recognise feelings, then assign numbers to her mood, etc. We're 5 years on and her school staff are still trying to desensitise her to the very small school setting.

DD3 was very unwell and was referred to CAMHS. She waited 6 months for an appointment, then they said that they needed to offer a DNAV-R group therapy course for her OCD, with a wait of 6 months. She was traumatised and out of school by that point, so there was no way she would be able to join a group of strangers online. They said they knew this, but they had to see her fail, then they would put her on a waiting list for individual therapy, another 9 months, which they knew would fail, then they could put her on the psychiatry waiting list, but the list was about 2 years long. By this point she had been out of mainstream school for a year and hadn't been able to engage with the special school staff who had been patiently working their way up the driveway.

Fortunately, she had already been on the waiting list for ASD assessment for 2 years and got her diagnosis, then someone paid for her to have a home visit from a CAMHS psychiatrist who also did private work (she couldn't leave the house by that point), who confirmed her OCD diagnosis and started medication. That allowed her to cooperate with the psychiatrist enough that he could do the QB check and diagnose her ADHD. The ADHD treatment allowed her to start engaging with her special school staff, eventually let them into the house, then start visiting school.

The psychiatrist tried to use EMDR but DD3 couldn't recognise her feelings enough to notice them in the moment. So now she's having a talking therapy with a Clinical Psychologist through her special school. It's slow progress.

DD1 is complicated by her LDs. She is having psychiatry and psychology support but it's hard to make any progress because she doesn't know what she's feeling and largely acts on impulse.