Autism

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.