Autism

The internet really did a number on me with the abbreviation CBT.

it hurts pretty bad

To me CBT basically feels like gaslighting yourself.

Cognitive Behavior Therapy is like an impacted, aching colon. It hurts, and all the books claim you can pass it all quickly, but the more you push, the more it hurts.

But then I may just be in the (alleged) 20% failure rate.

My experience is CBT treats everything like an addiction or cope. You give up the bad habit and experience the feels and address them.

But we don't smoke / drink / fap to snails drinking cappuccino / play WoW for 96 hour intervals just for fun. We're invaribly doing it because not doing the thing is riskier to our well being. Which is easy to do if the thing keeps us from taking on a suicide-inducing career. (Observe Captain John Yossarian trying to keep his liver fever because not doing so means flying bombing missions.) If your doing CBT because your boss / family / therapist wants you to get better so you can go back to working in the toxic mines, it's probably not going to help.

I once heard that therapists who put down that they're trained in CBT sometimes straight-up aren't, but it's listed as a specialty for insurance/money reasons.

That aside, CBT helps with retraining often irrational/harmful thoughts and feelings, like anxiety and things that may stop you from living a full life. Autism in itself is not an irrational or harmful thought-process. It's just sometimes an atypical way of thinking and connecting things.

Caveats: I'm self-suspecting, but not diagnosed autistic. I have taken CBT for depression, not social issues. It was as an adult, not an adolescent.

I found it pretty difficult to apply to my issues. I struggle to identify emotions and to attribute them to thoughts, particularly when I'm in distress. So it feels like CBT is aimed at a different type of mind. I found more success with therapies that center the body. Behavioural activation, mindfulness.

One unexpected benefit of CBT was that, through its worked examples, it gives an insight into how others think. Apparently people invest a lot of thought into imagining personal disasters. Who knew? No wonder so many people are anxious all the time.

I see a counselor who specialises in Aspergers, and he has suggested some things to help my anxiety that I think come from CBT (and they seem to work, albeit briefly).

IMO, as far as I know it can work, but I think there needs to be a specific "autistic version" of some things.

Or maybe that's just a universal thing and CBT should be customised for each person regardless of their neurotype.

I'm not sure if this is backed by research but my therapist has said that CBT isn't very effective for autistic folks.

It wasn't very helpful at all with my precious therapist so it checks out anecdotally for me.

IME it's good as long as the therapist is experienced with people with ASD

Not really helpful.

I found psychodynamic therapy more helpful.

I don't have time to elaborate much now, but I want to add my voice to the conversation.

I'm someone who often rants and rambles about the limitations of CBT. I think it's overused, is part of why. I've had 3 or 4 different courses of CBT, largely because I haven't been able to access any other kind of therapy. The last few years have been spent trying to get access to literally any other therapy and it's frustrating to be told time and time again that I'm "too complex". For me, it's about "right tool for the job" and there definitely are jobs where CBT is an ineffectual tool.

In this analogy, "jobs" aren't people, but particular situations and points in their life. Right now, I need basically any tool but CBT, because where I am now, I think more CBT would be actively harmful. I do feel that CBT was helpful for me, but that it has reached its limit in what it can offer me. I think the second course of CBT was probably useful, but anymore beyond that was pointless, for me. The second course was helpful because I wasn't in a place where I could effectively engage with the stuff the first time round, it feels like rereading what was once a difficult book.

It can very much depend on the therapist you get, but I think that's true for neurotypicals doing CBT too (which isn't to say that it affects equally, I think a therapist who you can't connect to is way harder to cope with as an autistic person, and probably more likely). But what I mean to say is that I think that CBT, when done well, has a lot of potential, especially as a front line treatment (it's very accessible to people who haven't done therapy before). There also branches such as trauma informed CBT, or eating disorder informed CBT, or indeed, neurodivergence informed CBT. I don't know anyone who has done CBT aimed at autistic adults, but I'm not the only autistic I know who felt CBT had helped them.

I think one of the tricky parts about CBT is how accessible it is. It is, in its base form, quite versatile, and can be tailored in more structured ways, as discussed above. It's probably useful to bring back my tool analogy here, because something that feels important is that when I talk about different tools, one valid way of looking at that is the therapy program by itself as the tool, existing separately from the therapist. In this framework, the therapist is someone who uses a particular tool to do a job, where the job is something that you're struggling with in life. This framing is useful because it allows us to think about bad therapists as people who are using a tool incorrectly.

I imagine most trained therapists have some knowledge or experience on how to use CBT as a tool, because it's so accessible. Some people become experts in one particular tool, and some people learn it and never use it again, but find their knowledge of that tool useful in understanding the overall landscape of what's available.

My point is trailing away a bit, so I'll try to sum up where I'm going with this. Some people say that CBT is an inherently harmful tool, even when used skillfully by a Good Therapist (TM). I disagree with that, but I sympathise. I see the harms they point out and in my opinion, that could be improved by having therapy in general be more accessible, especially more specialised therapy yours - I think CBT works as a first step, but only if it's not the last and only step. Some people believe that CBT is inherently harmful to autistics specifically. I think I disagree with this one, but I'm a lot more split.

Here are a couple of autism/disability specific limitations that I found: 1.) I am physically disabled in a way that makes it hard to budget energy. Sometimes I have to deal with situations where I need to do more than what my body is capable of, and if I push myself too far, I will make things much worse. I didn't find CBT techniques very useful for situations where I would be paralysed by anxiety because I'd be having to choose between wetting the bed and attempting to get to the bathroom and hoping I don't fall (it's easier to change a bedsheet than to come back from the acute injuries of a fall). No-one should have to make decisions like that, but I regularly have to and it sucks. My anxiety is pretty reasonable in those situations, I can't logic my way out of it with CBT methods. Once you get the bad brain stuff out of the way, what can remain is the fact that sometimes things just suck and have to be weathered. Excessive use of CBT thinking in these situations often led to internalised ableism, where I put too much onus on myself to do or think about things differently, when my disabilities do put some practical limitations on me.

2.) An autism related example involves how coping with change is rough. I have a particular cereal that I have had for years, it's my old reliable and is one of my safe foods. One day, I see that it's packaging has changed a little: nothing too major, just the shape of the box and one of the logos. This makes me anxious and I do not like it for reasons I can't explain. My CBT trained instincts might ask about why I'm anxious - do I fear that the formula has changed? Is the new box size likely to cause issues with storage? Realistically, none of these capture the issue (the formula change thing is a valid fear, but I checked online and got confirmation that the product itself was the same). I don't know why this makes me feel uncomfy and none of the therapists I've worked with have either. We hit a wall on this problem, which makes sense to me - like, as helpful as CBT has the potential to be, it can't realistically (and doesn't aim to) make me into a neurotypical. Maybe CBT tailored for autistics might be better, but I don't know.

So to cap off those examples, the question was "when used by a Good Therapist (TM) who understands autistic people, is CBT inherently harmful to autistics?" and my answer to that is that I don't know. I don't think so. I think it's probably limited in some ways, but I don't know if that's unique to CBT. Most if not all therapies are likely to share the same problem, because in my eyes, the harm here stems from a normative way of looking at things.

Brief vocab lesson, "normative" roughly means "things that are considered normal and acceptable at a systemic/societal level to the extent that they're built into the unspoken assumptions we make when perceiving the world". The unspoken assumptions are tricky. Like when I say I want garlic bread, I mean garlic bread with cheese, because that's the only way I have ever, or would ever have it. A friend inadvertently broke my heart by ordering the wrong thing (because I'd told them I wanted garlic bread). I was devastated, but it was an important lesson in how your unspoken assumptions can sneak up on you when you meet people who don't share them. Normativity is how those assumptions interact on a societal level. Like if I say "imagine a couple, in love", you probably imagine a man and a woman, which is an example of heteronormativity, the implicit belief that being straight is the default. This doesn't mean that imagining a straight couple in this scenario is bad, it's just a way of saying that we should be mindful of the consequences of normative thinking, especially when with responses that are automatic, or when we build stuff on top of our assumptions

In theory, being aware of this stuff could mitigate a lot of the autism related issues with CBT. I'd argue that the reason why ABA is so harmful is because normativity is baked into it. That's part of why I believe that ABA is always harmful, no matter the therapist. In my view, "Good Therapist" and "Good at doing BA" are mutually exclusive, and I wouldn't be comfortable getting therapy of any sort with someone who endorsed ABA.

In terms of other therapies, there's been some research on Dialectical Behavioural Therapy (DBT) for autistics, I believe. That's the one that's most been recommended to me (if I could get a bloody referral, angry sounds).

This got longer than planned because apparently I'm using this comment as an excuse to procrastinate, my apologies for rambling. I can't tell from your post whether your interest is academic in nature, or whether you're asking this because it's a possibility you're considering for yourself. If the latter is the case, my answer is squarely "worth a try". Bad therapists happen across the spectrum of different therapists, and much more common than that are therapists who aren't a good fit for a particular patient. It can take time to find someone you click with and even then, I remember spending most of my sessions thinking "ugh, I don't know what the point of this is, it doesn't make a difference". It did though, it just snuck up on me.

They are going to be more similar than different really. Both lean heavily on the B part of the name (applied Behavioral analysis, and cognitive Behavioral therapy), and at their core are learning new skills or behaviors that more effectively navigate the world (one not inherently designed around an autistic experience of the world(as if there was just one)). They are both about making behavior changes that lead to being more comfortable long term, and that usually revolves around practicing behaviors (often pretty frequently, which can be uncomfortable short term).

ABA at all, in any shape or form, is harmful. Its taking a person and saying, “The way you talk or act isn’t okay. We’re going to change you so that you talk and act like a different people group, and we’re going to ensure that pretty much your entire life is dedicated to this goal until we’ve achieved it.”

If someone chooses to get CBT, then there’s implicit consent. It’s pretty hard to do CBT without consent. ABA, on the other hand, is usually done to people who do not consent, which is abuse. The only reason it’s not seen as abusive is because Western society is so ableist that they consider anything that “changes” an autistic person to be more neuroconforming is acceptable, no matter how it’s achieved.

Hey so I'm not a therapist but I have some personal experience with CBT as an ADHD haver. I'm my humble opinion, people really need to not get their advice from an internet posting when it comes to this stuff. There's so much bad info (even in this thread) that I'm not sure how useful this reply will be, but CBT is a demonstratedly effective tool set for retraining internal dialog and consistently produces measurable improvements in mental health across a variety of metrics.

That said, only a licensed therapist will be able to judge whether or not it's the right fit for any one specific person. More importantly, CBT is only one of a variety of approaches and what seems to make even more of a difference is finding a good fit with the provider. That is to say, the best technique with a poor provider is going to be much less effective than a different approach from a provider you click with.

There are some really valuable tools in the CBT tool case. But there are a lot of valuable tools out there in general, and finding a provider who can help lead their patient to learn to use them is much much more important than which shelf they come off of.

All the best. It's not an easy process regardless, but well worth the effort.

There is research that supports the use of CBT with all populations, including autistics. However, I haven't really look into the studies' methodologies to really analyze the validity of it's claims. We just have to take the word of the authors unless someone wants to break it down for us or I get a special interest for it. Perhaps, when I get this ADHD crap figured out with the new psych, I'll be able to do it.

In my personal experience receiving CBT therapy, it can ave some helpful impact. It caused me to become even more aware of my feelings, behaviors, and why I behaved that way in an analytical sense. CBT taught me to assess every single thing I do and why. However, it can also be some gaslighting crap if autism-specific matters aren't addressed. For example, using CBT, I can insist on overriding my intuition because the facts of the situation don't match my feelings, so I come up with a different belief to feel different. Thus, it is not helpful in a lot of overwhleming situations that engage hypersensitivity. It's like I say to myself, "Based on these facts, I shouldn't feel overwhelmed, so I need to convince myself of that." It can also be unhelpful in social situations with manipulative people because they alter or misrepresent reality and their intentions, which then results in me overriding healthy boundaries.

Based on the research at face value and my personal experiences, I think that we could probably benefit from a CBT approach that it tailored specifically to autistics by considering hyper sensitivity, sensation seeking, and modules on social matters that include education and manipulative tactics, because the reality is that as autistics, we are prime targets for manipulative people.

I have found that psychodynamic and values-oriented therapy have been more helpful for me though. Psychodynamic can be really rough to experience since it involves a lot of emotional processing and is slowwwww. I have thrown up a lot of times going through psychodynamic therapy. Values-oriented therapy was helpful at redesigning my life, but doesn't address previous experiences, so put together, they were more helpful over all.

Not sure if it’s as applicable to your particular situation, but I’ve found “acceptance and commitment therapy” (ACT) to be a particularly effective therapeutic approach for myself.

A waste of time in my experience. I was having bad anxiety (then undiagnosed ADHD and Autism), and the CBT material basically boils down to “Just stop being anxious”. I don’t know if the material would be any different post-diagnosis.