Chapter 1: Understanding DBT and Its Challenges for Autistic People

Dialectical Behavioral Therapy (DBT) is frequently utilized for individuals on the autism spectrum due to their susceptibility to emotional dysregulation. However, when applied without modifications, it can have adverse effects.

Many within the Actually Autistic community recognize that Cognitive Behavioral Therapy (CBT) can be quite gaslighting for us. It posits that everyone has control over their thoughts and suggests that our cognitive distortions influence our emotions. This approach often implies that our concerns stem from incorrect beliefs or exaggerated fears. Yet, as an autistic individual, I find it nearly impossible to exert control over my thoughts. While I can address some cognitive distortions, the sheer volume of intrusive and interconnected thoughts makes it a daunting task.

Some beliefs may appear distorted, but that doesn’t mean they are. Events I perceive as catastrophic may not affect allistic individuals in the same way, yet for many autistics, such fears are grounded in reality. We regularly face rejection, bullying, social isolation, sensory overloads, public meltdowns, and judgment for our coping mechanisms, like stimming. Tragically, some of us even face severe dangers, including violence, particularly among BIPOC autistics. The risks we encounter are not merely distortions; they are genuine concerns.

You might wonder why I discuss CBT when this is about DBT. The reason is that DBT incorporates behavioral principles similar to CBT, focusing on altering one’s mindset. While DBT has proven beneficial for individuals with Borderline Personality Disorder and Bipolar Disorder, its effectiveness for autistic individuals often falls short, particularly when using conventional methods.

On paper, DBT appears to cater to autistic individuals due to our emotional dysregulation and intense feelings. Furthermore, the emphasis on interpersonal skills seems relevant, yet a deeper examination reveals significant issues. For example, one central component of DBT is mindfulness meditation. For many of us, being instructed to sit still can be excruciating. I’ve touched upon this issue in a previous article, so I won’t delve into it here.

Avoiding stimming or refraining from sitting in positions that provide sensory feedback is not trivial; it can be physically uncomfortable and distracting. While the Interpersonal Effectiveness Skills taught in DBT seem beneficial, they often conflict with our natural communication styles. These skills rely on allistic social norms that we may not grasp or choose to reject, leading us to feel pressured to mask our true selves, which can be detrimental to our health.

Although I find some emotion regulation techniques helpful and utilize them when I remember, certain distress tolerance skills can be harmful. Many of these techniques, such as self-soothing and radical acceptance—which encourages embracing adversity—can be misinterpreted by autistic individuals, leading us to mask our responses and neglect our own needs.

DBT also addresses thought management, borrowing heavily from CBT principles. While observing my thoughts without attachment can be beneficial, it becomes problematic when I’m led to believe that all my negative thoughts lack foundation. The "Check the Facts" practice aims to confront cognitive distortions. While some of my thoughts are indeed unhelpful, such as assuming everyone dislikes me, these feelings often stem from my experiences of bullying and rejection due to my autism.

The terms "Emotion Mind" and "Rational Mind" also present issues, as they can perpetuate ableist narratives. Emotion Mind is often portrayed negatively, while the dangers of over-intellectualizing through Rational Mind are largely overlooked. This perspective can be invalidating for autistics who lean towards rationality, as we may have been conditioned to suppress our emotions.

The implication that high emotion is inherently negative creates a binary mindset, suggesting that one must always rely on the "Wise Mind" to achieve balance. While this may be the ideal approach, the program often lacks the necessary nuance. It is possible that some practitioners misinterpret the concepts, teaching them inappropriately.

In general, conventional DBT is not very effective for us unless we are in a modified program led by a therapist who understands autism or is willing to adapt their approach. Adhering strictly to DBT can be detrimental, particularly as we tend to be strict rule followers.

Fortunately, there are now neurodivergent-friendly DBT resources available. The Neurodivergent Workbook for DBT Skills is one such book I can recommend, as it aligns with my personal experiences. It eliminates the Interpersonal Effectiveness Skills section—something others may disagree with—but introduces content that addresses sensory needs, encourages stimming, and adapts skills for our neurotype.

I wish that Marsha Linehan, the founder of DBT, would not only endorse separate workbooks for autistic individuals but also consider modifying the core skill sets to be more inclusive. Perhaps this is an unrealistic expectation, but I believe that integrating options for autistic individuals into traditional DBT literature could significantly enhance the therapy’s effectiveness for our community.

We represent a substantial segment of the population that this therapy aims to assist, either inadvertently through misdiagnosis or intentionally, as many of us have coexisting diagnoses of Borderline Personality Disorder. It may be time for DBT practitioners and Linehan to embrace radical acceptance, reevaluating how this therapy can better serve autistic clients.

In this insightful video, Sarah Immerman discusses how to adapt DBT for autistic individuals struggling with emotional dysregulation.

This video offers ten practical tips for tailoring DBT to better meet the needs of autistic clients, providing valuable insights for both therapists and individuals.