As you may know, I am not only a patient with autism/ADHD/bipolar disorder, but I am a researcher with a PhD in Psychology from UCLA. My training has included exposure to various therapies, particularly including ABA, CBT, and DBT (check out my first-author paper on DBT). This post is a quick guide to different kinds of therapies, starting with behaviorism and then evolving over time to include second and third wave therapies. I’m evaluating them based primarily on my subjective understanding as a patient, but also with regards to the scientific literature.

Behaviorism (First Wave Therapies)

These therapies are based on the basic principles of behaviorism (Pavlov, for instance) and concern themselves with observable behaviors.

ABA: The controversial modality which usually dictates early intervention for autism is basically straight behaviorism. First, a behavior plan will be drawn up which includes antecedents (triggers), behavior, and consequences (which may or may not reinforce a behavior). ABA basically involves changing the consequences to change the behavior. Desired behaviors are reinforced using a small reward (like an M&M, although caution should be taken about using food rewards). Unfortunately, sometimes, punishment can also be used to change an undesired behavior. I don’t personally find this appropriate, and I think if you see this being done you should change interventionists. It is harmful to target innate autistic behaviors or intense interests with an extinction plan.

Exposure: Although extinction (for example, to treat a phobia by systematically exposing the patient to the thing they fear until their level of distress declines) is extremely effective, typically, the therapy causes distress — thus, patients often find it unacceptable. Starting with a different kind of therapy may help. A variant of pure exposure called Exposure & Response Prevention (ERP) is effective at treating some patients with OCD. In ERP, the patient is exposed to a trigger and prevented from performing the compulsive behavior that is aimed at neutralizing the obsession (which is caused by the trigger).

Second Wave Therapies

These therapies evolved from behaviorism to include thoughts, feelings, and other internal stimuli.

CBT: This modality is common in the wild, but it is often low quality. When you do find high quality CBT, it may be particularly helpful for people with severe mental illness (bipolar or schizo spectrum) who have anosognosia (low insight) to increase understanding of their illness. As a person with high levels of insight, I did not find it particularly helpful most of the time.

Third Wave Therapies

These therapies, like second wave therapies before them, evolved from CBT to emphasize mindfulness and acceptance of unwanted thoughts or feelings.

Acceptance and Commitment Therapy (ACT): Unwanted thoughts and feelings often cause distress. However, if you do not fight against the unwanted thoughts or feelings, and instead accept them and move forward with your life, you can reduce the suffering those thoughts or feelings cause you. This is the central observation of ACT.

Dialectical Behavior Therapy (DBT): Marsha Linehan developed DBT to help people who met the profile of Borderline Personality Disorder (BPD), especially those at high risk for suicide. However, watered-down versions of the DBT model are common, for example, in inpatient hospital settings. The full DBT model involves a weekly skills group, weekly individual therapy, and phone coaching. It is expensive and often these programs do not accept insurance. However, this approach is what started me on a different life path.

Non-Evidence Based Therapies

Psychoanalysis or Psychodynamic: I had a psychodynamic therapist briefly. I’d be interested to try it again, since I’ve tried everything else.

Eye Movement Desensitization and Reprocessing (EMDR): Some people swear by EMDR, but it is not considered an evidence-based treatment. That doesn’t mean it’s not worth a try, though.