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Externalizing Metaphors Therapy for Anxiety in High-Functioning Autism

Overview and Implications

Individuals with high-functioning autism, traditionally characterized by a lack of comorbid intellectual disability, are highly susceptible to anxiety disorders, as indicated by an approximately 40% co-occurrence rate (van Steensel et al., 2011). Although people with autism are often excluded from clinical trials for treatment of anxiety, individuals with both of these disorders are associated with higher rates of self-injury, depression, and functional impairment, than individuals with only one of these disorders (Kerns et al., 2015). Thus, finding treatment options for the anxiety experienced by people with autism is a topic of interest within autism research. 

In order to adjust for the differences in social interaction and information-processing of people with autism, the therapy explained in this paper teaches people with high functioning autism how to externalize a problem, create a metaphor to represent it, and generalize that metaphor to apply to other aspects of life, which can be achieved within four therapy sessions. These four sessions each have a major theme or goal: externalizing a problem, metaphor development, metaphor shift or creation of a new metaphor, and generalization and maintenance. 

Since most traditional anxiety treatments do not do not accommodate for the unique way that patients with autism think, this therapy intervention provides an alternative for individuals with both disorders that may prove to be more effective than other therapies designed for neurotypical individuals. 


This article was thorough, giving detailed descriptions for each step of the treatment model. In particular, it provided a case illustration in order to give the readers a fuller understanding of how each session complements the rest. Overall, the goal of this review was to inform mental health care professionals of EMT intervention in a clear and concise manner, which I believe it succeeded in.

One disadvantage of EMT is that it is specifically designed for people with high-functioning autism. Thus, this treatment may not be a viable option for individuals with low-functioning autism, and other treatment options should be explored. Furthermore, although this treatment has much potential to help people with autism with their anxiety, it is novel, meaning that more research must be conducted before we can verify that it consistently produces positive results for clients. However, if the treatment passes clinical evaluations, it may provide a cost-effective treatment option for individuals with high-functioning autism to reduce their symptoms of anxiety.

Future Directions

As previously stated, future clinical research should look to further evaluate the effectiveness and efficacy of this treatment before more individuals begin to utilize this therapy. Other studies could also begin to research other therapy options for anxiety since, like neurotypical people, one type of treatment will not work for every individual who tries it. For example, cognitive behavioral therapy for treating anxiety is another area of ASD research that has garnered much interest due to its positive results in clinical trials (Clarke et al., 2017). 


Clarke, C., Hill, V., & Charman, T.(2017). School based cognitive behavioural therapy targeting anxiety in children with autistic spectrum disorder: a quasi-experimental randomised controlled trail incorporating a mixed methods approach. Journal of Autism and Developmental Disorders, 47, 3883-3895.

Kerns, C. M., Kendall, P. C., Zickgraf, H., Franklin, M. E., Miller, J., & Herrington, J.(2015). Not to be overshadowed or overlooked: Functional impairments associated with comorbid anxiety disorders in youth with ASD. Behavior Therapy, 46(1), 29–39.

Van Steensel, F. J. A., Bögels, S. M., & Perrin, S.(2011). Anxiety disorders in children and adolescents with autistic spectrum disorders: A meta‐analysis. Clinical Child and Family Psychology Review, 14(3), 302–317.

Article Reviewed

McGuinty, E. F.,  Bird, B. M.,  Nelson, J.,  McGuinty, J. L.,  Cashin, A.  Novel four‐session treatment intervention for anxiety and high‐functioning autism: A single case report for Externalizing Metaphors Therapy. J Child Adolesc Psychiatr Nurs.  2018; 31: 87– 96.

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