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Case Example: Joshua

About Joshua

Joshua is a 15-year-old boy who has autism spectrum disorder. His cognitive ability is in the average range. Joshua’s parents brought him to the clinic because he seemed worried about attending school and occasionally refused to go, and the school reported that he was having frequent arguments with other students. His parents hope that therapy might address Joshua’s difficulties, but Joshua is not so sure that talking to someone will help, although he is willing to try.

In the first two sessions, the therapist met Joshua and his parents, reviewed clinic policies and got signatures on necessary documents, and began to gather information, both directly from all of them and by asking for other relevant background information. Joshua said that he believes other teens are making fun of him. This makes him feel nervous and uncomfortable in social settings, and he starts arguments with peers. Based on these initial sessions with Joshua, the therapist decides that CBT is likely to help him address his current challenges.

At the third session, the therapist introduces the cognitive model to Joshua. Her clinical impression from the initial visits is that Joshua is a concrete thinker who tends to struggle with abstract language. She identifies and uses a visual support showing the relationship between thoughts, feelings, and behavior. She also uses another visual support to help Joshua identify and report his emotional states. In the initial assessment the therapist asked about Joshua’s special interest, and he mentioned SpongeBob SquarePants. With this information, she could identify—and ask Joshua to identify—meaningful examples of anxiety-producing scenarios and of thoughts, emotions, and behaviors to incorporate in discussion.

In the course of their work together, she notes that Joshua benefits from repetition of both content and practice when learning new strategies. At the end of each session, he repeats what he has learned to his parents and demonstrates what he has learned. Then, the therapist assigns homework, providing Joshua and his parents with a visual reminder of what to do, so he can remember, and they can assist with reinforcement and feedback.