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Cognitive Behavioral Therapy

Cognitive Behavioral Therapy, also known as CBT, is a psychological intervention that helps an individual recognize and understand the impact of their thoughts and feelings on their behaviors.

CBT may be used alone or together with other therapies to deal with a mental health condition.

What is Cognitive Behavioral Therapy? – Mental Health Center Kids

The CBT triangle, also called the cognitive triangle, is a tool that illustrates the relationship between how we think, feel, and behave. It’s one of the essential components of cognitive behavioral therapy.

The tip of the triangle represents our thoughts, while the bottom right and left points represent our feelings and behaviors, accordingly.

The CBT Triangle: What it is and How it Works – Mental Health Center Kids

Trauma-Focused CBT (TF-CBT)

  • Created for children who had experienced abuse. Expanded to help children and youth who had experienced any form of trauma; includes the family.
  • One skill from this therapy I still use with all ages is the Trauma Timeline where we create a timeline of major events which we intentionally process as potential roots to current distress and dysregulation.
  • Also has emphasis on grief – which helps!
AuDHD_Therapist ND Affirming Mental Health on Instagram
How This Type of Therapy Can Be Helpful for ADHD

CBT, like any form of therapy, can sometimes be misused to correct or reframe someone’s thinking in a way that’s invalidating or even gaslight people into doubting their own reality, especially when therapy isn’t done in a collaborative way with client

Because it focuses on cognitive distortions or thinking errors it can be easy for us to jump to the conclusion that our thoughts must be wrong especially if we’re being told that by someone we trust which is something those of us already dealing with cognitive challenges are susceptible to.

Used properly though, CBT should be collaborative and based on hypothesis testing.

How This Type of Therapy Can Be Helpful for ADHD – YouTube

CBT and the CBT triangle can be useful tools, but they can also be problematic for neurodivergent, traumatized, and marginalized people.

CBT: You’re wrong for being upset about your oppression and neglected pain. You’re overreacting. Stop it.

Mindfulness: You can’t control the future. Be in the present. Oh, you’re in pain 24/7 INCLUDING the present? Uh…take a deep breath?

Alana Saltz on Twitter

And this leads us to a criticism of both CBT and stoicism. Is there a danger that we’re encouraging people to accept things that they really shouldn’t have to?

Ancient Therapy for Modern Problems: Stoic Philosophy Explained – YouTube

CBT and Autism

Reflections on CBT and autistic thinking: Webinar for professionals03 02 23

Autistic children are anxious.

We treat them using CBT.

They learn to mask their anxiety, so the adults believe they are improved.

When the masking wears off the adults see the anxiety again and belief it is a relapse. – The relapse is the relapse of the masking.

If the children’s feelings are not important outcome of therapy, why do we send them to therapy?

Reflections on CBT and autistic thinking: Webinar for professionals03 02 23 – YouTube

Missing from the triad:

  • Sensory stimuli
  • Interpersonal relations
  • Interoception
Reflections on CBT and autistic thinking: Webinar for professionals03 02 23 – YouTube

The major problem for CBT is it assumes disordered thinking which can be altered. Maybe sometimes the autistic way of thinking is not disordered, maybe it is actually correct.

Reflections on CBT and autistic thinking: Webinar for professionals03 02 23 – YouTube

What CBT asks autistic people to do?

  1. As usual, try to survive sensory stimuli: sounds, lights etc.
  2. Find out what you are feeling and put words to it
  3. React accordingly to CBT – if you are happy and calm, do nothing
    if anxious, go to CBT
    if you can’t figure out what you are feeling, then what?
  4. Find out what your bodily sensations are
  5. Figure out what you are/were thinking
    by this time, you have had many other thoughts
  6. Remember what you are supposed to do
    behaviour, challenge your thoughts
  7. If you remember what to do, do it
    if you don’t remember, then what?

So it puts much more on autistic people than non-autistic people because the way the brain works.

And this all is putting an enormous pressure on processing speed and memory.

And then we come again to evaluating your thoughts, CBT is all about evaluating your thoughts, but there is a problem there because autistic people have had their thoughts and beliefs doubted since they could talk. It is the most common experience of all autistic people. They are constantly doubted.

There was also another problem because many autistic people in therapy have been just questioning their thoughts and feelings every day, and they claim it’s anxiety provoking. They describe this as fueling their anxiety, and now they go to therapy and the therapist tells them, “you know you should question yourself more”. And it is just a fact that constantly questioning your personal experience is going to lead to anxiety. And also it can increase self-blame.

Reflections on CBT and autistic thinking: Webinar for professionals03 02 23 – YouTube

Special interest is a part of autism

Special interest not something autistic people can stop or snap out of

Can be detrimental when people focus too much on their thoughts and feelings Therapy can in my experience trigger this or make this worse

Sometimes feelings, thoughts, sensations or mental health can become a special interest (generally called “obsession” by NT or “hypochondria”)

Reflections on CBT and autistic thinking: Webinar for professionals03 02 23 – YouTube

In CBT wrong diagnosis means wrong model & wrong treatment

Depression (behavioural activation) VS Burn out (rest)

Social anxiety (exposure) VS Autistic social style (change social circumstances)

Anger (self control ) VS Meltdown (prevent the situation)

Phobia (exposure to the “danger” ) VS PTSD (never exposed to similar event)

Reflections on CBT and autistic thinking: Webinar for professionals03 02 23 – YouTube

For me, a CBT focus in itself is unhelpful. All it does is point out more things I “should” be masking and teaches me to put more effort into masking rather than understanding myself and others properly. It taught me that the things I do and think are “wrong”, which increased my anxiety and convinced me I was making up my feelings and problems.

Quote from Scottish Survey of Autistic Adult’s experiences of counselling, 2020 by Sonny Hallett

I call CBT: “The therapy where you look at yourself in a mirror and lie to yourself”.

One of my Icelandic clients, 2023, Reflections on CBT and autistic thinking: Webinar for professionals03 02 23

In CBT I learned a lot of new technical words. After CBT I had the feeling there was something more wrong with me. I even felt that I was doing something wrong.

One of my Icelandic clients, 2023, Reflections on CBT and autistic thinking: Webinar for professionals03 02 23

When autistic young people who present internally go unrecognised, they are likely to be struggling with anxiety, depression and other mental health problems, as well as poor self-esteem (Livingston and Happé, 2017). This can be due to feeling different from their peers, not receiving the right support for their needs, or feeling forced to mask their difficulties. Unrecognised autistic people who present internally may also have difficulty developing a sense of their own identity (Mogensen and Mason, 2015) and can develop unhelpful coping strategies such as self-harm, eating disorders or self-medicating with drugs or alcohol. They may be offered therapies such as CBT for their mental health without these being adapted for use with autistic people, meaning they are often ineffective.

Autism, Girls, & Keeping It All Inside

Clinical studies show Daan’s experiences are far from abnormal. Therapy that is focused on battling “irrational beliefs,” such as cognitive behavioral therapy (CBT), doesn’t work as well on Autistic people as it does on neurotypicals.[72] One reason for that is many of the fears and inhibitions of Autistic people are often entirely reasonable, and rooted in a lifetime of painful experiences. We tend to be pretty rational people, and many of us are already inclined to analyze our thoughts and feelings very closely (sometimes excessively so). Autistics don’t need cognitive behavioral training to help us not be ruled by our emotions. In fact, most of us have been browbeaten into ignoring our feelings too much.

Recently, Daan switched therapists. His new therapist had only taken one continuing education course on Autistic adults in her entire career, but that still made her better informed than most providers. She sent Daan to get assessed, and began to read up on how to alter her therapeutic practice to fit him better.

“My new therapist admits there isn’t much research on helping Autistic people work through trauma,” he explains. “But she at least got me evaluated. And that has unlocked a world of understanding for me, because it’s helped me talk to other Autistics online.”

Unmasking Autism: Discovering the New Faces of Neurodiversity

If you suspect you have an unhealthy relationship to drugs or alcohol, it will be important to identify a treatment method that suits your neurotype, or find a mental health provider who has experience with Autistics. Since a growing body of research suggests cognitive behavioral therapy (CBT) approaches don’t work as well for Autistics as they do for neurotypicals, CBT-based addiction treatment might not be a good fit—at least not without modifications. One exploratory clinical study published in 2019 did find that when mental health providers were taught about how to communicate effectively with Autistic patients (a skill set most providers lack), the cognitive behavioral therapy they offered did help Autistic adults with their substance use disorders.

Unfortunately, most care providers are not well informed about how Autistic people think and communicate, and there is very little published research into which addiction treatment programs consistently work best for adult Autistics. Many of the effective treatment plans that do assist Autistic adults involve making sure our health care, housing, and other material needs are also being met, in addition to ensuring we are plugged into a network of supportive people. Often the fears that CBT therapists train their patients to view as irrational (if I say the wrong thing, I’ll lose my job and wind up on the street!) are completely rational for Autistics, and rooted in genuine experience.

Unmasking Autism: Discovering the New Faces of Neurodiversity

Therapy based on these models can be

  • Unhelpful (when models point to wrong targets in therapy)
  • Increase problems (when models point to wrong targets in therapy)
  • Increase self-blame (blame themselves when therapy doesn’t work)
  • Increase anxiety (because situations never get easier, it teaches doubting your feelings, thoughts)
Reflections on CBT and autistic thinking: Webinar for professionals03 02 23 – YouTube

Therapy: Discover your needs

Because autistic people are often denied their needs in childhood they often don’t know their own needs

Most autistic people are raised in families with NT-typical value system & society has the same value system

Therefore they need to learn what needs they have & that they have the right to have their needs and not NT-needs

Reflections on CBT and autistic thinking: Webinar for professionals03 02 23 – YouTube

The major problem for CBT is it assumes disordered thinking which can be altered.

DaisyGirl on National Autistic Society’s chat, 2014

CBT and Rejection Sensitive Dysphoria (RSD)

If a patient does not benefit from medication, they have little control over an episode of RSD once it begins. The incidents have to run their course. Some people with ADHD, however, report that getting interested in something new and fascinating can help to end an RSD episode more quickly than it would otherwise. In my clinical experience, neither coaching nor traditional psychological or behavioral therapies — like CBT or DBT — offer any prevention or relief from impairments. Nonetheless, many people report that it is very helpful for them to know that this highly disruptive experience is real, common, and shared by other people with ADHD. “It helps me to know what is happening to me and that it is ultimately going to end.”

What Is Rejection Sensitive Dysphoria? ADHD and Emotional Dysregulation

Cognitive behavioral therapy might allow people to better understand their triggers, and equip them with healthier coping mechanisms when they feel an RSD episode coming on. However, CBT and other therapies are considered less effective for RSD than they are for other mental health conditions, in part because of how quickly an episode of RSD can be triggered. Although therapy may be helpful, mindfulness can also help people with RSD control their emotional reactions.

Rejection Sensitive Dysphoria: What You Should Know About ‘Emotional Sunburn’

CBT and Chronic Illness

For example, I was repeatedly made to do CBT for my insomnia (at least 4 times until now) but except for the first time, which was before my fibromyalgia was triggered, it never really worked. In fact, the last time (about 6 months ago), it very nearly broke me. That is when I started questioning whether generic treatments like this will work for people with chronic conditions (especially with various co-morbidities) without individual attention.

5 things I’ve learned from #NEISVoid (No End in Sight) – A Painful Identity

CBT and Oppression/Minority Stress

The “CBT Triangle” is a visual which shows how our Thoughts influence Feelings which influence Behavior:

  • Basis: thoughts create our reality.
    Change your thoughts, especially “faulty beliefs” + your feelings and behavior will improve = problems solved.
  • While CBT can be helpful with skills like “reframing thoughts”, it fails to be inclusive of ‘problems’ caused by systemic oppression (which cannot be overcome by simply changing our thought patterns).
AuDHD_Therapist ND Affirming Mental Health on Instagram

Therapy is one only option: While many folks have felt supported in therapy, not everyone can access it, not everyone wants to access it, and for some people, it simply hasn’t been helpful. Most dominant therapeutic techniques were developed with a white Eurocentric understanding of psychology and trauma, and approaches such as CBT can cause more harm to marginalized people.

Barriers to Intervention — Project LETS

Further reading,