Dialectical Behavioral Therapy & Autism: An Empowering Set of Skills5 min read

Dialectical Behavior Therapy (DBT) is a form of therapy meant to help vulnerable people to empower themselves.  Developed by Marsha Linehan to treat suicidal women with Borderline Personality Disorder (BPD), this therapy is commonly used to treat people with PTSD, substance abuse and addiction disorders, and mood disorders as well.

Autistic folks can gain a lot from this from of this form of treatment.  DBT uses validating environments to encourage self-driven change meant to improve individual quality of life.  It helps us regulate our emotions and navigate social situations.

It gives us skills that equip us for effective self-advocacy.

Quickly, a disclaimer: Though this is a therapy aimed at altering behaviors, it is in no way about conversion or compliance.  Instead, DBT focuses on acceptance and mindfulness to build a sense of self that is integrated and accountable, authenticity and imperfection that work together.

During its development as a therapy, DBT was shaped to avoid making people feel criticized or invalidated, something that causes great suffering in people with BPD.  The changes encouraged in this treatment are largely driven by the person involved and are geared towards skill building and empowerment.

The Overlap Between Autism and BPD

Traits like emotional dysregulation and social difficulties are present in both.  There is likely a biological component to this for both groups, meaning our brains are wired to be more vulnerable to emotional difficulties.

We’re also more vulnerable to things like rejection and experience higher rates of trauma, especially in our early years.  In fact, while autism exists before the trauma is experienced, BPD is thought to be directly related to prolonged exposure to trauma, much like complex PTSD.

Another common component with both diagnoses is the increased tendency towards suicidal ideation or self-harm thoughts and behaviors.  DBT was developed specifically to address these issues.

The Components of DBT

DBT was built on three tenents:

  • Biosocial Theory – Some people are neurologically vulnerable to emotional dysregulation.  Invalidating environments makes this worse.  This can lead to self-harm, as the strong emotions have nowhere to go in the invalidating environment.
  • Dialectical Philosophy – Two opposing forces cannot exist together without balance.  Neither is complete without the other.  Balance between the two forces heightens the effectiveness of each.
  • Acceptance/Mindfulness – Acceptance practices include radical acceptance, distress tolerance, mindfulness, and emotional awareness.  It’s a great practice for cultivating a solid sense of identity, an authentic self that allows the person to be flawed and still feel their worth.

There are several areas of focus in DBT that are used to establish lasting skills in a person’s life:

  1. Mindfulness – This is the act of noticing and being present and in the moment.  This practice encourages us to gain understanding of our emotions and personhood through the purposeful act of awareness without judgement.  Through this practice we can learn to identify how our needs are expressed by our bodies.
  2. Regulating emotions and distress tolerance – This is the practice of recognizing and managing emotions as they come up.  Emotions are viewed as important parts of our humanity and our survival.  By learning to recognize them, we are able to intervene on overwhelm earlier.  This can help prevent overwhelm and gives us tools to avoid self-harm when we do become over-stressed.  Giving ourselves productive outlets for even our toughest emotions is key to our well-being.
  3. Interpersonal Effectiveness – DBT teaches people about boundaries and how to gauge the intensity of a situation.  For example, If a person asks a favor of me, and I don’t want to do it, I can say no.  This is a low intensity situation, though it may feel differently.  However, when a person ignores my no, they have increased the intensity, so the degree that I assert my no should increase.  The ability to set and respect good boundaries is essential to healthy relationship building.  
  4. Crisis Intervention – Part of DBT involves establishing care plans for when emotions do overwhelm.  There are group and individual therapy environments geared towards learning and practicing these skills.  Support is provided for moments of crisis as well, so that you don’t have to navigate challenging environments with brand new skills alone.  

How This Applies To Autism

While developed with BPD patients in mind, the theories transfer to autism-specific issues.  This focus on balance, awareness, nonjudgement, and calculated change can provide a structured, approachable way for autistic folks to unmask.

Acceptance and emotional regulation practices help us develop care plans to use as interventions when our emotions begin to get overwhelming.  These include things like changing the environment to suit our sensory needs to prevent meltdown, as well as how to deal with a meltdown and the care required after having one.

Focusing on social navigation reduces the vulnerability autistics struggle with in social settings.  The breakdown on boundary setting is especially helpful, as is the concept of wise mind.  These concepts teach us to recognize red flag behavior and protect ourselves from those who target us.  They can also help us navigate conflicts and prevent us from alienating people who are not abusive, but are still upsetting or misunderstanding us.

Improving our emotional and social lives will go a long way to protect us from self-harm and suicidality.

Do This Instead of ABA

The heart of DBT is the assumption that we are capable beings.  Treatment is geared towards building up those capabilities and generalizing them outward, multiplying them through guided practice and mindful effort.

Linehan sought to dismantle the stigmas surrounding BPD and to humanize the people who needed these interventions.  She built this treatment from within a world that wrongly assumed people with BPD were beyond help.  Her research shows what can happen when people’s struggles are seen as valid, but not defining.

Her work has reshaped how we view BDP and has saved many lives.

Imagine what life would look like for an autistic kid exposed to Linehan’s mindset as they developed.  Imagine the independence this could give to autistic adults– the healing potential, the stigma-busting power.  This is a social support worth investing research and resources in.

References:

Chapman A.  L.  (2006).  Dialectical behavior therapy: current indications and unique elements.  Psychiatry (Edgmont (Pa.  : Township)), 3(9), 62–68.

Dudas, R.  B., Lovejoy, C., Cassidy, S., Allison, C., Smith, P., & Baron-Cohen, S.  (2017).  The overlap between autistic spectrum conditions and borderline personality disorder.  PloS one, 12(9), e0184447.  doi:10.1371/journal.pone.0184447

Van der Kolk, B.  A., Hostetler, A., Herron, N., & Fisler, R.  E.  (1994, December).  Trauma and the development of borderline personality disorder.  Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/7533284

7 Comments

  1. This article is so interesting to me.  I have been told I have BPD, I laughed when I was told this, and I was given no information about what BPD was; I felt it was a complete nonsense and that actually the mental health practicioner really had no idea what was going on in my life, and I was being appeased.  Im 55.  My son is a school refuser and Ive had a difficult time getting support from services and support agencies, I have had to home school, as we were living in trauma as no one has believed me when i have shared about my sons difficulties at home, or heard me when i tried to question if he has ADHD or autism.  I have been BLAMED for his school refusal.  I know I am not fully to blame.  Anyway I have been questionning if I may be autistic, or my son, now reading this has helped me to consider the differences between BPD and Autism, and I am beginning to at last begin to think I am getting closer to some sort of understanding of myself……………..ultimately I pray this will help me support and nurture my son with more integrity and skills to prevent him living in emotional trauma and confusion all his life.  I am due to attend the Distress Tolerance course soon and think this article has prepared me to “listen” better and “hear” better the teaching and advice on offer on this course.  I have done the Emotional Regulation Course, i found i was unable to process this at the time but as the weeks and months go by I am understanding it better and more able to see that actually, I may indeed have, BPD, and this is okay with me.  I feel a new road open up for myself, one of more understanding and empowerment.  I know many people with autism, or friends and aqaintences with children with autism, who self harm, or have tried to commit suicide, and it feels at last things are coming together and im finally beginning to understand more about autism.  It is a fight literally to be heard by CAMHS , they discount parents experiences with their child, and the difficulties day to day that they are experiencing, they are told they are over anxious, worrying about nothing, the proffessionals arrogance is damaging and in fact adds to the trauma already being felt by the families and children who seek support.  I know because this has been my experience.  there is LIFE and HOPE when people accept what you say, do not judge, and then stay with you……………………….until an understanding and tools are discovered to carve out your way through the difficulties.  This feeling of acceptance and not being judged , alone is life affirming!!  KNOWLEDGE is empowerment.  Articles like this are so incredibly important to helping to gather understanding of yourself or others.  Why professionals hold closely to their chest such information is almost unforgivable.  HUMILITY is required in our professional support services.Thank you so much once again for this article.

    1. Author

      First of all, I’m sorry that you’ve been blamed for your son’s difficulties.  That’s an awful, all too common experience.  I remember trying to avoid school because there was so much sensory and social overwhelm.  I could barely cope.  I was told I was too pretty to be homeschooled and that was the end of that.  I would have given anything to have a parent like you who advocated for me in that time.  Good luck with your upcoming course.  It can take a while to notice that you’ve built new skills, but there will be little signs here and there that you’re making progress.  Then one day you’ll be like, “Oh hey!  I’ve really come a long way.”  At least, that’s been my experience. 

  2. My therapist recently opined that DBT would probably be useful for many autistic people, and I agreed.  It’s nice to see other people discussing this too.

    I’d like to add that DBT is also recommended as a treatment for complex PTSD.  While I don’t believe there’s data yet, I’ve noticed that many autistics have complex PTSD.

    1. Author

      I 100% agree with you.  My exposure to DBT was from treating C-PTSD.  And I agree that a lot of autistic folks seem to share that comorbid diagnosis.  It sucks.  We deserve better.  My favorite thing about DBT is that is was specifically developed to help people who deserved better but were told by society that they were lost causes.  It subverts that idea and is successful. 

      1. Yeah.  And I love its approach.  Instead of saying “okay, what are you doing wrong that is making you upset,” it says “life stinks sometimes so let’s figure out how to deal with it.”

        Because sometimes stress doesn’t come from “thinking errors.”  Sometimes a situation just stinks.  And instead of blaming yourself for causing the distress, you focus on how to cope with it.

        1. Author

          Exactly!  I love that.  My therapist suggested that my goal be “to be resilient in a world that judges.”  It was so validating, and it helped me consider the possibility that I had power and choices in life.  It was also daunting as hell, but what good challenge isn’t.  Lol!

          1. That is a beautiful goal.  I think I’ll aim to do the same.

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