Therapy Overview: Dialectical Behavior Therapy

About the Author

Kelly is a Senior Manager of Individual and Family Services and a LifeMAP Coach at AANE. She worked at McLean Hospital using DBT to teach women emotion regulation tools and other life skills to move forward in their lives. Kelly helps navigate what autism means for individuals and their loved ones.

What is DBT, and what mental health conditions can it address?

DBT, or Dialectical Behavioral Therapy, is an evidence-based mental health treatment. While DBT has been used to treat Borderline Personality Disorder (BPD) and suicidality, it is suitable for a range of diagnoses and can be best thought of as treatment for anyone struggling with emotion dysregulation. The ultimate goal is for clients to build a life they believe is worth living. Comprehensive DBT entails 4 modes of treatment:

• Individual Therapy Session (typically once/week): Involves learning how to collaboratively and non-judgmentally observe and analyze “target behaviors” to understand the function they serve and increase or decrease them. A diary card and chain analysis are two of the primary tools used. Examples of treatment targets include emotions, skills and other behaviors such as masking, substance use and avoiding school or work.
• Skills Training Group (typically once/week for 6 months): While it’s called a group, it’s more of a class with a set curriculum to teach the skills. There are four modules: Mindfulness, Emotion Regulation, Distress Tolerance and Interpersonal Effectiveness. Some people benefit from just participating in a skills group (in addition to their non DBT therapy). There are also Multi-family Skills Groups. These are generally only available for adolescents and their caregivers, but there may be young adult/caregiver options available.
• Skills Coaching: In order to help with skills generalization outside of the therapy space, phone coaching is available from the therapist between sessions. This is not another therapy session; it’s a short structured interaction to get in the moment help with applying DBT skills. 
• Consultation Team (for the therapists only): a weekly meeting for therapists to get consultation and support in order to be more effective in their work.

As with any therapy, what someone decides to work on and what behaviors they “choose to target” is up to them, with the exception of any life threatening behaviors which are the highest priority target. These are addressed like any other target via diary card tracking and chain analyses to understand the function and identify how best to intervene. In addition to the behavior therapy foundation, DBT utilizes eastern mindfulness practices and “dialectics”. The core dialectic in DBT is about balancing both acceptance and change. 

How might DBT be helpful for Autistic individuals, and what are some recommended adjustments for Autistic clients?

DBT can be a very helpful form of therapy for some Autistic individuals. Of course this is not a blanket recommendation, but for Autistic folks (or anyone) who experiences intense emotional suffering and deals with a lot of dysregulation (whether it presents internally or externally), it’s worth at least learning more. 

• The Biosocial Theory is the underlying theory that DBT utilizes to explain how emotion dysregulation difficulties develop and are maintained. In short, this is attributed to the combination of a heightened biological sensitivity coupled with an invalidating environment. I often hear Autistic folks talk about the world being “too loud” or that they’ve always had a “sensitive nervous system.” Given the fact there’s sadly no shortage of invalidating environments, Autistic folks have experienced, it’s easy to see how significant emotional dysregulation could occur. 
• DBT was developed in response to limitations of Cognitive Behavioral Therapy (CBT): many clients experienced it as invalidating due to its heavy focus on change. Rather than eliminate the change focus, which can leave people feeling stuck, DBT added a focus on acceptance (and dialectics). Acceptance strategies include learning how to validate or in other words, recognize how what someone is doing, thinking, feeling makes sense when the context or function is understood. Given the high degree of invalidation Autistic folks experience, an explicit emphasis on validation can be healing.
• Becoming more dialectical (learning how to hold two seemingly opposing ideas at the same time) can be enormously helpful for all or nothing thinking styles and patterns of behavior.
• Many Autistic individuals describe not knowing what to do in therapy and find themselves just talking but not understanding the expectations or seeing forward movement. DBT Sessions are structured based on prioritized treatment targets that the therapist will explain and help uphold. Further, the class-like format of the DBT Skills Group can be additionally grounding.

Keep in mind it is typical to feel uncomfortable in the course of therapy because making changes and approaching painful emotions isn’t easy. Setting that expectation is important so that feeling badly is not misinterpreted as something necessarily being wrong.  At the same time, it’s also very important to remember there’s a difference between uncomfortable and harmful. While someone may be unhappy with their therapist or the therapy process at times, the therapist’s job is to help their client reach the goals they identified and should ultimately feel like an ally. If they don’t, talking to a trusted person about it (if possible) could be helpful. While it can be challenging to do, it is always the client’s right to bring up concerns with their therapist or ultimately end therapy altogether; that does not mean the client failed and in fact, one of the explicit “assumptions in DBT” is that clients cannot fail in DBT.

Resources

• Charlie Swenson’s podcast episodes on Autism, Neurodiversity and DBT (Two guests, Amara Brook and Rachel Kraus, are neurodivergent DBT therapists who are currently working on a book for professionals about adaptations to DBT for neurodivergent clients)
• Neurodivergent Friendly Workbook of DBT Skills (Note: this does not include the Interpersonal Effectiveness module)
• What is Dialectical behavior therapy (DBT)? (Short video with animation)
• The Family Connections Program (For family members of loved ones struggling with emotion dysregulation)