Is Neurodiversity Affirming DBT Just Another “Good ABA”?
This document is open for feedback. Contact me at tasha@tashachemelcoaching.com or through the THRP.
Dear DBT Therapists,
I am writing this letter to express my concern about the growing number of mental health professionals who believe that Dialectical Behavioral Therapy (DBT) can be tailored to meet the needs of autistic clients. This letter is a call to self-reflection.
Right now, active debates are occurring between Applied Behavioral Analysis (ABA) practitioners and neurodiversity advocates about whether ABA and other behavioral therapies can be adapted to be neurodiversity affirming. Despite DBT being a behavioral modality, proponents of neurodiversity affirming DBT, many autistics among them, have excused themselves from these debates by focusing on the differences between DBT and ABA, implying that while ABA cannot be adapted to be safe, DBT can. These practitioners claim that DBT differs fundamentally from ABA because it does not commit ABA’s core sin of trying to treat autism and instead targets symptoms that prevent clients from achieving their goals.
It is dangerous to believe that dressing up a therapy modality as “affirming” is enough to make it safe. As with ABA, DBT uses the therapeutic relationship as a reinforcer so that clients will become more amenable to learning behaviors that allow them to better function in the oppression of late capitalism, without critical analysis of the inherent harms in doing so. As with ABA, neuronormativity is still present, regardless of whether autism is treated or superficially “affirmed.” As with ABA, DBT omits critical consideration of the ways in which clients’ goals, even if autonomously created, have been influenced by systemic and ongoing trauma. As with ABA, DBT neither includes nor validates discussion of how treatment itself can be traumatic. As with ABA, clinicians’ belief that teaching a prescribed set of skills will lead to empowerment allows them to retain their own sense of goodness, while supporting the very systems that keep their autistic clients subjugated.
Autistic clinicians can be both oppressed and oppressors. To our clients, we are not only “good (i.e. employed) disabled people,” but also representatives of the group (medical and mental health professionals) who have abused so many of them. While maintaining our own respectability and coping with pressures placed on us to uphold the integrity of evidenced-based practices, it is inevitable that we will identify with and collude with our clients’ perpetrators. This is what Judith Herman refers to as “traumatic transference.” It can occur in all situations where clients discuss prior abuse, but can be exacerbated if lateral ableism causes therapists to blame clients for not doing enough to prevent their own mistreatment. Indicators that these dynamics are playing out are often subliminal and therefore easy for behaviorists to miss. When clients come to us seeking skills to better function in a neurotypical or ableist world, and we provide little else, we are tacitly implying that we believe responsibility lies with them, not with their abusers and larger systems of oppression.
This is my own story. I am a white, late-diagnosed autistic. I am congenitally totally blind and grew up in an affluent Boston suburb. As a child I was subjected to harmful educational and therapeutic interventions that were ostensibly designed to equip me with the tools I needed to reach my goals of going to college and living on my own. I chose these goals, but I did not choose the price I was expected to pay in order to achieve them. I was told that I needed to learn to tolerate all sorts of mistreatment, and to politely educate teachers, peers, and the general public about blindness. The failure to center social and disability justice in the care I received meant that I was left without any language to understand my experience or to normalize my rage. Worse than that, I was disenfranchised from accessing my own natural reactions to injustice. My big feelings were labeled counterproductive, and I was rarely allowed to just be dysregulated, even though that’s what my body and nervous system so badly wanted.
Ironically, I was hurt most by well-meaning blind adults who thought that if I could learn the strategies they had mastered, I could acquire their level of respectability. This is an example of traumatic invalidation that therapists may unwittingly impose on clients. When we prescribe individual skills as a solution to sociopolitical problems, we pathologize clients’ reasonable responses to others’ misuse of power. Ableism operates by selling us the myth that if people are treating us badly, it is because we are not calm or skilled enough to make ourselves understood. Teaching neuronormative communication skills, even while simultaneously uplifting autistic ones, is not like teaching our clients two equally valid languages. It is never a neutral act.
Does allying ourselves with this modality truly serve our community, so many of whom have already survived other compliance-based interventions and provider saviorism and self-idealization? Additional research is needed, but I believe that autistics with more neurocognitive privilege and less exposure to the corrosive effects of compliance trauma are more likely to find it helpful, or at least are at less risk of harm. To my knowledge, neurodiversity affirming practitioners have been silent about DBT’s coercive elements, such as withdrawal of warmth and contingency management. Regardless of whether more trauma-informed and sensory friendly aspects are added, and punitive components are omitted, DBT (like ABA) has its origins in behaviorism, in carceral and compliance-based systems. Commitment strategies are still coercive, even if their purpose is made more transparent. I fear isolating the DBT skills from the therapeutic protocol, as Sonny Jane has done, just makes DBT’s systems of punishment and coercion less visible.
Does this approach meet the needs of the multiply disabled and the multiply marginalized? Neurodiversity affirming DBT is rooted in the social model of disability, which has given us many victories. But the social model has also perpetuated a seductive discourse around accommodations, the idea that if we are given the right tools, supports, and skills, it is possible for us to be placed on equal footing with our nondisabled peers. In contrast, through its focus on intersectionality and interlocking oppressions, disability justice draws attention to the reality that this equal footing is defined by colonialism and white supremacy, and is only available to a very small subsection of our community.
Neurodiversity affirming DBT practitioners stress the importance of helping clients differentiate between changes they want to make and those imposed by others. Is that even possible if trauma erodes agency and identity, damaging our ability to know ourselves or identify the goals that make our lives worth living? Skills training should not be used to bypass the need for trauma treatment. While not every modality is a good fit for everyone, do we run the risk of harming clients while they are in the process of determining whether DBT is a fit, or whether it is simply replicating the abusive dynamics with which they are all too familiar? Given these risks, can we claim that neurodiversity affirming DBT is not a continuation of “good ABA” for adults?
Does distancing ourselves from ABA and other behaviorist modalities, then, become yet another way that therapists evade true humility? Yes, the term “neurohumility,” as defined by Rachel Kraus in a recent paper that appears in the August 2024 edition of the DBT Bulletin, refers to “a stance and a self-reflective process wherein one maintains curiosity, respect, and humility toward the lived experience of other body-minds.” While curiosity and respect are necessary, what Kraus and others in the discourse omit is the uncomfortable truth of our own ongoing potential to do harm, no matter how many choices we offer, no matter how many modifications we provide. Without this expressed acknowledgement of and grappling with our power, these “affirming” concepts fall short of true humility.
My critiques of neurodiversity affirming DBT are consistent with broader patterns I have seen through my research for the Therapy Harm Resistance Project. As care workers, most of us came into the field because we want to do good, because we have wisdom and tools that we are hoping to share with others. When many therapists we have interacted with first come into contact with the concept of therapy harm, their initial instinct is to hold fast to the thought that if they do X training or follow Y ethical guidelines or modify a modality with Z adaptations, they can avoid doing harm. I understand this instinct, but urge you to begin the process of overriding it in favor of deeper, more liberatory work. Part of my journey has been dismantling my unshakeable attachment to my own goodness. While it is vital that we strive to mitigate harm through every means available, the stance from which these efforts emerge matters. In our attempts to attune to and address harm, we must notice where our egoic need to be “good” shows up and influences what we are able and willing to grapple with. As Jennifer Mullan writes in Decolonizing Therapy, ”If we are not made to feel uncomfortable, how will we change? If we are not asked to look long and deeply at our collective shadow as an industrial complex, how can we be pushed to deeply bring about lasting change?”
This is the call I make to my fellow mental health and care professionals. We need to talk not just about whether we can tailo
Tasha Chemel, Ed.M., MSW
This letter, reprinted with the author’s permission, was originally published on the Patreon of the Therapy Harm Resistance Project
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About the Author
Tasha Chemel (she/they) is an executive functioning coach and autistic advocate. She is a co-founder of the Therapy Harm Resistance Project, which provides education and advocacy resources for therapists and therapy harm survivors. She lives in Washington, DC with her adorable orange cat, Willa.