When CBT Stalls: Could Missed Neurodivergence Be Part of the Problem?

When CBT Stalls: Could Missed Neurodivergence Be Part of the Problem?

Written by Annika Okamoto, PhD

Some people do everything their therapist asks. They show up every week, speak openly, complete worksheets, and still do not improve. Sometimes they feel worse.



For clients, this can feel like proof of failure. For therapists, it can be demoralizing, leading them to question their effectiveness or attribute the lack of progress to personality or motivation.

There is another possibility: neurodivergent traits may be missing from the clinical picture. I trained at the Harbor-UCLA CBT/DBT clinic and use both approaches daily. But even good treatment can fail when the formulation overlooks context or neurobiology.

CBT, DBT, and the map

Cognitive behavioral therapy (CBT) helps people understand and change how thoughts, feelings, behaviors, and bodily sensations interact. Dialectical behavior therapy (DBT), developed from CBT, focuses on teaching people emotion regulation, distress tolerance, and interpersonal effectiveness.

Both also depend on a shared understanding of the problem, which therapists call a formulation. Think of it as a map of what triggers a difficulty, how you respond, and what keeps it going.

What does neurodivergent mean?

Neurodivergence is an umbrella term for differences in how brains process information and navigate the world. Autism and ADHD are common examples.

Many people reach adulthood without a diagnosis, particularly if they are bright and learned early to meet social expectations. Social camouflaging appears to be more common among autistic women (Hull et al., 2020) who may have learned early to “be nice.” If you have always been called “too sensitive,” “too emotional,” “too intense,” or “too much,” this may resonate with you.

People in this situation may arrive in therapy with several diagnoses: anxiety, OCD, depression, PTSD, or a personality disorder. These may capture real distress, but some difficulties may also reflect coping responses to an unrecognized neurodevelopmental profile. Navigating a neurotypical world as an undiagnosed autistic or ADHD individual can be chronically invalidating and, for some, traumatic.

What differs in how a neurodivergent brain works?

ADHD and autism are different patterns, not opposites, and many people have both.

ADHD is thought to involve underactivity and poor signaling in some brain systems supporting attention and impulse control. It may seem counterintuitive to prescribe stimulants to someone who already appears hyperactive. Think of someone trying to finish a work task while feeling sleepy. But when they drink coffee and put on music, the extra stimulation helps them stay alert. This may be why novelty and interesting tasks help, and why some people with ADHD may be unusually chatty or move around a lot. It may look like misbehavior but may be an effort to sustain alertness. In one study of children with ADHD, more movement was associated with better working memory performance (Sarver et al., 2015).

In autism, one leading theory is that some areas of the brain are more sensitive to incoming signals, so the brain takes in more information than usual. This can make it hard to filter out irrelevant details and focus on what matters most. A person may notice their conversation partner's gaze, their tone, their clothing, or a humming light in their room and miss the meaning of what was being said. The science is not settled, and this is a working model rather than a certainty.

Why treatment stalls

If sensory overload, exhaustion, or a need for predictability is missing from the formulation, treatment may target the wrong problem. For example, assigning homework to someone already experiencing burnout and difficulty initiating tasks may add to the problem rather than help resolve it.



When too much information arrives at once and the nervous system struggles to regulate, a person may appear to be “overreacting” or having a “meltdown.” Internally, they may be managing a flood of sensory and emotional input. 

In a questionnaire study of 156 adults, sensory-processing sensitivity was associated with borderline and avoidant personality features (Meyer et al., 2005). Research on neurodivergence specifically is still developing, but when treatment stalls, sensory and neurodevelopmental factors deserve consideration.

Common therapist pitfalls with missed neurodivergence

1. Sensory or executive overwhelm is treated as avoidance.

A client avoids work documentation, so the therapist uses the therapeutic approach called motivational interviewing to address ambivalence. But the client may be genuinely exhausted by the sustained reading, writing, and organization the task requires. Another client avoids Costco on Saturday afternoons, so the therapist creates an exposure ladder. But the lights, noise, and crowds may cause genuine sensory overload. Rather than always trying to change the person to fit the environment, we may need to change the environment to fit the person.

2. A need for order is mistaken for an obsession or compulsion.

Imagine someone who becomes distressed by a new piece of furniture in the bedroom because it changes how familiar and predictable the room feels.

A therapist might interpret this reaction as OCD and use exposure and response prevention, asking the person to resist putting things right. But neurodivergent distress may feel more visceral, arising when something violates predictions about how the environment should be. A certain order may feel safe and predictable; and a change in it feels like a note played out of tune.

A better question is: What does this rule do for you, and what does it cost you? Sometimes the answer is to keep the rule and help other people understand it. Sometimes the cost is high enough to work on loosening the rule.

3. Overwhelm and unmet needs are overlooked.

Self-harm may be misunderstood when its function is to numb feelings of overwhelm, quiet the mind, or cope with strong emotions. Suicidal thoughts may also occur alongside burnout after years of trying to conform to social norms and manage overwhelming daily demands. An online survey of autistic adults found that masking and unmet support needs were associated with higher scores on a measure of suicidal thoughts and behaviors (Cassidy et al., 2018). If the therapist focuses only on a diagnostic label without exploring these experiences, the client may hear, “You are the problem.”

4. Conserving social energy is treated as a failure to practice social skills.

A therapist might encourage someone to make more eye contact, smile, or attend more parties to learn that nothing bad happens. The person may not want to look people in the eyes because they are exhausted by multitasking during the social interaction. Is that person socially anxious? Maybe. But the social anxiety may have developed only after repeated feelings of inadequacy due to a low social battery drained by unknowns. The answer isn't always more exposures.

What adequate CBT looks like

Good CBT is more than a well-executed protocol. A thoughtful therapist does not let a few salient behaviors determine the diagnosis. Instead, together with the client, they build an understanding of the problem, ask what each behavior does for the client, test the formulation collaboratively, and revise it when treatment stalls.

Symptoms worth a closer look

Whether you are a client or a clinician, the following patterns may warrant further exploration. None of them is a tell-tale sign of neurodivergence; some also occur with anxiety or trauma, and many neurodivergent people do not experience all or even most of them.

Worth exploring:

• Sensory differences: Cutting out clothing tags, difficulty filtering noise, using noise-canceling headphones, keeping blinds closed during the day, frequent bruising or tripping, strong food or texture aversions, or rigid rules about order.
• Daily living difficulties: Struggling with cleaning, shopping, laundry, or other routine tasks even with average or high intellectual abilities.
• Social difficulties: Problems emerging around middle school, when friendships become more complex; missing subtext or repeatedly misunderstanding others.
• Interpersonal conflict: Being told you’re too rigid or stubborn, too reactive or impulsive or that you have anger problems.
• Attention and impulse regulation: Interrupting, difficulty sitting still, fidgeting, skin picking, or over-focusing on details. Forgetting and misplacing things, losing a train of thought.
• Emotional distress: Self-harm that quiets overwhelming thoughts or feelings; chronic anxiety, depression, or multiple overlapping diagnoses. Self-medicating with alcohol or drugs.

If you are in therapy

If you trust your therapist, consider asking:

• “Can you walk me through how you understand what is happening for me?”
• “What would we change if this plan isn't working?”
• “Could neurodivergence or sensory sensitivity be part of the picture?”
• 
  

If you are a therapist

Ask about sensory experiences and daily routines early. Explore what a behavior does for the person, build recovery time into the plan, and consider referral for assessment when appropriate.

Keep the original diagnosis in view: both neurodivergence and another mental health condition may be present.

About the Author

Annika Okamoto, PhD, is a licensed psychologist and an Adjunct Faculty member in the MACP program at Antioch University Santa Barbara. She earned her PhD in Health Psychology from Alliant University and completed postdoctoral training with frequently incarcerated, hospitalized, and homeless individuals, including work at Harbor UCLA Medical Center and the UCLA Semel Institute. She is a Diplomate of the Academy of Cognitive Behavioral Therapies, a board member of the National Social Anxiety Center, and clinical director of a small nonprofit serving people with mental health disabilities and low socioeconomic status. She is also Past President of the Santa Barbara Psychological Association. Her expertise includes mood and anxiety disorders, therapeutic alliance, and working with neurodiverse populations, and she is committed to supporting marginalized communities and advancing social justice.

Links

Dr. Okamoto’s clinic website:

https://www.oceansideclinics.com/oceanside-clinics-ca-telehealth

The book Alliance Rupture Repair in Cognitive Behavioral Therapies, edited by Dr. Okamoto:

https://link.springer.com/book/10.1007/978-3-032-07140-8

References

Cassidy, S., Bradley, L., Shaw, R., & Baron-Cohen, S. (2018). Risk markers for suicidality in autistic adults. Molecular Autism, 9, Article 42.

Hull, L., Lai, M.-C., Baron-Cohen, S., Allison, C., Smith, P., Petrides, K. V., & Mandy, W. (2020). Gender differences in self-reported camouflaging in autistic and non-autistic adults. Autism, 24(2), 352–363. https://doi.org/10.1177/1362361319864804

Meyer, B., Ajchenbrenner, M., & Bowles, D. P. (2005). Sensory sensitivity, attachment experiences, and rejection responses among adults with borderline and avoidant features. Journal of Personality Disorders, 19(6), 641–658. https://doi.org/10.1521/pedi.2005.19.6.641

Sarver, D. E., Rapport, M. D., Kofler, M. J., Raiker, J. S., & Friedman, L. M. (2015). Hyperactivity in attention-deficit/hyperactivity disorder (ADHD): Impairing deficit or compensatory behavior? Journal of Abnormal Child Psychology, 43(7), 1219–1232. https://doi.org/10.1007/s10802-015-0011-1

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