Can Cognitive Behavioural Therapy (CBT) be used with neurodivergent people?
Cognitive Behavioural Therapy (CBT) is the most widely used form of psychological therapy globally. CBT is often recommended by health professionals for a wide range of physical and mental health problems, including anxiety, depression, obsessive-compulsive disorder (OCD), eating disorders, sleep difficulties, chronic pain, chronic fatigue, irritable bowel syndrome, and substance use problems. There is extensive research evidence that supports the use of CBT for these difficulties.
CBT is founded on the theoretical framework that centres thinking (cognitive) problems and learned behavioural patterns as the primary causes of psychological problems. CBT therapists aim to improve well-being by helping people change unhelpful thinking and behaviour patterns using strategies that include the following:
- Cognitive restructuring: Challenging thinking “distortions” that contribute to problems such as “all-or-nothing thinking,” “black and white thinking,” “catastrophising,” “shoulds/oughts/musts,” “overgeneralising,” and “personalising”
- Exposure and response prevention (ERP): Unwinding avoidant patterns by encouraging the person to take action in the presence of fear and anxiety.
- Behavioural activation: Encouraging a person to engage in activities to improve their mood, such as increased socialising, exercising, or spending time in nature.
- Mindfulness and relaxation: Practising activities that can relax the body and quiet anxious thinking, such as progressive muscle relaxation and mindfulness activities.
CBT can be used with Autistic and ADHDer people; however, like all therapeutic approaches, it must be adapted to suit the person and remain affirming. If you are using CBT as a therapist, there are a few things it is helpful to consider:
Cognitive restructuring:
Many Autistic people describe cognitive restructuring (attempts to change thinking patterns) as feeling like “gaslighting.” For many Autistic people, this process may feel like they are being told their thinking is “wrong,” when it is just different. Autistic people and ADHDers frequently experience discrimination, stigma and prejudice. Be careful not to imply that this is “all in their mind” or that they are “catastrophising.”
Exposure and response prevention:
If an Autistic or ADHDer person is in burnout they will have very few internal resources available to them to undertake challenging exposures and they will struggle to put the plans they make in therapy into action.
Many exposure activities involve sensory and social stressors that can be uncomfortable for Autistic people and do not get easier or more comfortable with time. ERP approaches must consider this and work to reduce stressors as much as possible. Such avoidance is protective and self-compassionate rather than problematic.
Behavioural activation:
Be careful not to set goals that focus on attaining normative ideals and expectations. An example of this would be encouraging an Autistic/ADHDer to socialise more with their friends in a restaurant or bar, when the sensory environment is uncomfortable and draining, and the activity triggers burnout and exhaustion.
Behavioural activation can be particularly unhelpful (and even harmful) when a person is in Autistic/ADHD burnout. In burnout, a person does not have the capacity to take on new activities and may feel like they are failing therapy. In fact, to recover from burnout, the person often needs to reduce what they are doing and change their expectations to accommodate their sensory, social and executive functioning needs.
Therapy with a person who is in Autistic/ADHD burnout can often be long-term. Recovery from burnout will typically take months or even years. It’s likely that the person will never get back to their original level of functioning, because this wasn’t sustainable for them. As a therapist you may begin to wonder if what you are doing is helping, and insurance may not cover the amount of support needed.
Mindfulness and relaxation:
Autistic people and ADHDers may find it more difficult to sit still and quiet their mind. They may also find it more challenging to establish a routine and practice this regularly, even if they find it helpful.
A good starting point is using everyday activities as opportunities to focus their attention, such as when walking, colouring, or brushing their pet. Incorporating movement into the activity can be helpful. Practices should also be short – just one minute is ideal.