DBT Skill Training for Autistic Adults With Difficulties in Emotion Regulation: a Feasibility Study.
Phase: NA
Conditions: Difficulties of Emotion Regulation, Self-harm Behavior, Autism Spectrum Disorder
Sponsor: Helse Møre og Romsdal HF

 
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DBT skill training for autistic adults with difficulties in emotion regulation; a feasibility 
study  
 
 

 
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Protocol: DBT skill training for autistic adults with difficulties in emotion regulation.  
Johanna Vigfusdottir1,2, Erlend Mork3 Reidun Høidal1, Ina Grønset1, Lorie A. Ritchel4, Alexis 
Brewer4, Anita Johanna Tørmoen, Inga Wessman6 & Egil Jonsbu1,2 
1 More and Romsdal Hospital Trust, Molde, Norway. 
2 Norwegian University of Science and Technology, NTNU, Trondheim, Norway. 
3 Oslo University Hospital, Oslo, Norway.  
4 University of North Carolina School of Medicine, Chapell Hill, NC, USA. 
5 Nasjonalt senter for selvmordsforskning og forebygging 
6 University of Iceland 
Introduction 
Autism Spectrum Disorder (ASD) is a lifelong neurodevelopmental condition characterized 
by challenges in social interaction, communication, sensory sensitivities, and restricted, 
repetitive behaviors and interests (American Psychiatric Association [APA], 2013). ASD 
presents heterogeneously among individuals and is more prevalent than previously 
recognized. The Centers for Disease Control and Prevention (CDC) reported a significant rise 
in ASD prevalence, from 1 in every 2,222 children in 1968 to 1 in 44 children in 2020 
(Maenner et al., 2020). This increase is attributed to evolving definitions, greater awareness, 
and methodological differences in studies (Zeidan et al., 2022). Notably, much of the recent 
rise in prevalence involves autistic individuals without intellectual disability or with minimal 
language impairments, often remaining undiagnosed until adulthood (Lord et al., 2022). 
Undiagnosed ASD is particularly prevalent in adult clinical populations. For instance, a 
Swedish study found that 18.9% of psychiatric outpatients had ASD, with another 5-10% 

 
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exhibiting subthreshold symptoms (Nyrenius et al., 2022). Psychiatric comorbidity is 
common in ASD, with over 70% experiencing at least one psychiatric disorder and a 
prevalence rate well over 50% compared to the general population (Underwood et al., 2019). 
Common co-occurring conditions include anxiety, depression, ADHD, obsessive-compulsive 
disorder (OCD), bipolar disorders, and sleep-wake disorders complicating both diagnosis and 
treatment (Lord et al., 2022). Additionally, autistic individuals frequently engage in suicidal 
behaviors, non-suicidal self-harm, and aggressive behaviors, significantly impacting daily 
functioning (Lord et al., 2022). 
Autistic women with without intellectual disability are often underdiagnosed because their 
symptoms can be less overt, and they may be adept at "camouflaging" their difficulties, 
mimicking socially acceptable behaviors, and suppressing autistic traits, leading to increased 
internal stress and delayed diagnosis (Bargiela et al., 2016; Livingston et al., 2019). 
Misdiagnosis with personality disorder are common, in particularly misdiagnosing autistic 
women with borderline personality, with traits often observed in this population contributing 
to this risk (McQuaid et al., 2024). 
Despite increasing diagnosis rates, there is a significant gap in evidence-based treatment 
options for autistic adults, particularly concerning comorbid mental disorders (Maddox et al., 
2020). Many mental health clinicians lack adequate training to work with autistic adults and 
may avoid both assessing and treating them, while ASD specialists often lack expertise in 
treating co-occurring mental health conditions (Maddox et al., 2020). According to a report 
from the Norwegian Official Report committee published in 2020, many autistic individuals 
do not feel their needs for treatment and assistance are met. There are some structured 
treatment options available for autistic children and adolescence, and for autistic adults with 

 
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intellectual disabilities. There is a serious lack of treatment options for autistic adults without 
intellectual disabilities within the psychiatric hospitals in Norway (Paulsrud et al, 2020). 
Emotion regulation difficulties are increasingly recognized as central challenges for many 
autistic adults. Shared mechanisms contributing to poor emotion regulation across clinical 
populations include physiological arousal and alterations in brain regions like the amygdala 
and prefrontal cortex, while unique mechanisms in ASD involve differences in information 
processing, cognitive rigidity, and disorganized emotion regulation (Cai, 2018; Mazursky et 
al., 2013). Autistic adults often struggle with alexithymia, exacerbating emotion regulation 
issues, and sensory sensitivities and social communication challenges can further trigger 
emotional dysregulation, necessitating targeted therapeutic interventions (Cai et al., 2018). 
Emotion regulation difficulties in autistic adults can manifest as an inability to recognize, 
understand, and manage emotional responses, leading to maladaptive strategies and behaviors 
such as meltdowns, self-harm, violence, and avoidance. Developing effective emotion 
regulation strategies can significantly improve quality of life for autistic individuals (Cai et 
al., 2018). 
Dialectical Behavior Therapy (DBT) posits that emotion regulation deficits are central to 
complex symptom presentations. Originally developed for patients with BPD who engaged in 
self-harm and suicidal behaviors, DBT teaches skills to recognize, modulate, and tolerate 
emotions effectively (Linehan, 1993). Full standard DBT has shown effectiveness in reducing 
self-harm and suicidal behaviors among autistic adults (Huntjens et al., 2024). While DBT 
does not, and should not, aim to cure autism, it can help autistic individuals develop skills to 
navigate their emotions, relationships, and crises, enhancing their ability to reach their 
personal goals and build a life worth living. 

 
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A feasibility and acceptability study of DBT skills training was conducted among autistic 
adults without intellectual impairment and suicidal ideation in community clinics in North 
Carolina, USA (Ritschel et al., 2022). However, similar studies have not been conducted in 
the Nordic countries for patients in outpatient psychiatric hospital settings. This study aims to 
evaluate the feasibility and acceptability of DBT skills training among autistic adults in 
Norway seeking treatment at a psychiatric hospital, incorporating adjustments from the 
previous USA study to suit the learning styles of autistic adults without intellectual 
impairment. 
 
Primary objectives 
1. If the DBT-skills training is relevant - The severity of difficulties in emotion 
regulation for the population, and the presences of destructive behaviour such as self-
harm and suicide behaviour. 
2. If DBT-skills training is accepted by tracking the dropout rate from DBT skills 
training, as well as the percentage of DBT-SUD skills sessions participated in, and the 
percentage completed homework.  
3. Acceptability and Feasibility post treatment by evaluating participants' experiences 
with the treatment, and use of unhelpful and helpful strategies with self-rapport 
instruments. 
Secondary objectives 
1. Tracking the change in two target behaviours and four target emotions and use of 
skills in the treatment period with a diary card. 

 
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2. Assessing goals, hinders, and resources at the start and completion of the DBT skills 
training, with a qualitative interview.  
 
Study Design 
This study is a mixed-method feasibility study without a control group. With measurements 
pre and post treatment intervention  
To determine if implementing the intervention is feasible and acceptable, and to gauge 
potential benefits for future randomized controlled trials (RCTs), a traffic light system will be 
employed. "Green" will indicate that the progression criteria are met, warranting a full trial; 
"amber" will indicate that criteria are partially met, necessitating revisions before a full trial; 
and "red" will indicate that the intervention is not feasible, accepted, or safe, or that potential 
benefits do not justify proceeding to a full trial (se table 1). 
 
Recruitment of participants: 
Data collection 
A convenience sample of 10 – 15 patients in the out-patient clinic in More and Romsdal hospital 
trust, Molde in Norway, that fit the inclusion criteria will be invited to participate in the project. 
We will collect data at the start of the treatment and in the follow up session in the 1-2 weeks 
after completion of skills training.  
Inclusion criteria for the study: 
1) Fit general inclusion criteria for the out- patient treatment at the clinic.  
2) Have diagnosed autism, and pervasive difficulties in emotion regulation. 

 
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3) Speak Scandinavian (Norwegian, Danish and/or Swedish). 
4) Manage to commit to participating in the DBT- skills training. 
5)  Be willing to sign the written informed consent. 
General exclusion criteria for the study:  
1) Have a clinically significant low linguistic functioning that hinders the patient in 
understanding and answering the questions on the self-report instruments. 
2) Being actively psychotic.  
3) Have a Body Mass Index (BMI) under 17. 
4) Cognitive disability IQ <85 
The intervention  
The intervention period will be from April 2025 – October 2026.  
DBT- skills is a group skills training component of Dialectical Behaviour therapy a comprehensive 
treatment focused on extensive difficulties in emotion regulation (Linehan, 1993). In this project, we will 
use the standard DBT skill-training model by Linehan (Linehan, 2014) with an addition of Autism 
specific interventions and adjustments (Ritchel et. al 2022). Every patient participating in the DBT skills 
training is assigned a DBT-trained therapist, for orientation, half-way evaluation and summary (3-5 
sessions). While in skills training the participants will continue their standard out- patients treatment with 
their regular therapist (individual therapy, medication management). 
The DBT-SUD Skills intervention consists of:  
- 
2-3 sessions with a DBT therapist focusing on treatment orientation – mapping the patients' 
goals, obstacles, and resources, DBT- hierarchy, and commitment.  
- 
Skills training – 28, two-hour sessions – once a week. The skills consist of:  
o Mindfulness 3 x 2   
o Distress Tolerance x 7 
o Interpersonal Effectiveness x 6 

 
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o Emotion regulation x 7 
- 
One status and evaluation session half-way through the skills training. 
- 
One summary session with a focus on goals reached and troubleshooting. 
Two DBT therapists lead the group, and each group consists of approx. 4-6 participants.  
Measurement  
Demographics. Basic demographic information from the participants is registered. This includes 
age, gender, nationality, level of education, employment/support status, living situation, marital 
status, children, co-occurring psychiatric diagnosis, and medical status. 
Cognitive disability.  
Wechsler Abbreviated Scale of Intelligence (WASI) is a brief measure of general intelligence designed 
for use with children and adults between the ages of 6 and 89 years. The WASI requires approximately 30 min 
to administer the full test and 15 min to administer the abbreviated test. The full test consists of four subtests; 
Vocabulary (V) and Similarities (S) subtests combine to measure VIQ (verbal– crystallized abilities), and 
Block Design (BD) and Matrix Reasoning (MR) combine to measure PIQ (nonverbal–fluid abilities). The 
abbreviated test consists of two subtests, Vocabulary and Matrix Reasoning, which combine to assess general 
intelligence. WASI subtests are scaled in T score units (M =50, SD=10), and the IQ scores are scaled in 
traditional IQ– standard score units (M=100, SD=15). Four IQ scores are provided for the WASI and include 
the Full-Scale IQ–Four Subtest (FSIQ-4), Full-Scale IQ–Two Subtest (FSIQ-2), Verbal IQ (VIQ), and 
Performance IQ (PIQ) (Psychological Corporation, 1999). 
Emotion regulation.   
Difficulties in Emotion Regulation Scale 8 items (DERS-8) is a shortened self-report 
instrument, developed from the original DERS-36 meant to measure difficulties in emotion 
regulation (Gratz & Roemer, 2004). The DERS-8 consistist of 8 items prefaced with the 
phrase “When I’m upset,” to provide respondents with a uniform context that elicits thinking 
about situations requiring regulation of negative emotion; answers to items likely to represent 

 
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affect, thought, and actions in response to such situations. The scale offers a brief 
unidimensional measure of difficulties in emotion regulation for adolescents and adults. Items 
are scored on a 5-point Likert-type scale (1 = almost never (0–10%), 2 = sometimes (11–
35%), 3 = about half the time (36–65%), 4 = most of the time (66–90%), and 5 = almost 
always (91–100%)). Scores (8 – 40) are summed to yield a total score. Higher scores indicate 
greater levels of difficulties in emotion regulation (Penner et al., 2022). 
Aversive behaviours: Self-harm, Suicide behaviour.  
Inventory of Statements About Self-Injury (ISAS) consists of two sections ISAS 1 that assesses 
lifetime frequency of 12 Self-harm behaviors performed “intentionally (i.e., on purpose) and 
without suicidal intent. Five additional questions assess descriptive and contextual factors 
(Klonsky & Glenn, 2009). Those endorsing one or more self-harm behaviour are instructed to 
complete the second section of the ISAS. The second section assesses 13 potential functions of 
the self-harm through 39 different statements: affect- regulation, anti-dissociation, anti-suicide, 
autonomy, interpersonal boundaries, interpersonal influence, marking distress, peer-bonding, 
self-care, self-punishment, revenge, sensation seeking, and toughness. Each function is assessed 
by three items Likert scale: “0-not relevant,” “1- somewhat relevant,” or “2-very relevant”. 
Thus, the scores for each of the 13 ISAS functions can range from 0-6 (Klonsky & Glenn, 
2009). The functions of self-harm measured with ISAS show a robust 2 factor structure 
(Klonsky & Glenn, 2009).The instrument has been used in research among autistic adults 
(Newell et. al., 2024) and has been assessed for Norwegian population and found to have sound 
psychometric properties (Vigfusdottir, et. al, 2020).  
Columbia-suicide severity rating scale (C-SSRS) is a suicidal ideation and behaviour-rating 
interview created to evaluate suicide risk. The interview consists of 10 categories with binary 
responses (yes/no) to indicate a presence or absence of the behaviour. The outcome of the C‐
SSRS is a numerical score obtained from the categories (Posner et.al. 2011).  

 
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Dropout from treatment: 
Dropout is registered, and dichotomous variables are created (yes/no). In case of dropout, 
number of skills sessions is registered and the reason given for dropout.   
Feasibility and acceptability 
To measure acceptability, we register proportion of DBT-skills training sessions they 
participated in, the completion of assignments completed and frequency of use of skills 
registered on a diary card. 
Participants Satisfaction Questionnaire is a self-rapport questionnaire developed to measure the 
satisfaction of autistic adults participating in DBT skills training (Ritschel et.al, 2022). The 
satisfaction is measured by answering 30 questions about: General satisfaction, satisfaction with 
the procedures, and Outcomes on different areas (social, emotional, Cognitive, self, behaviour, 
quality of life). The questions are answered on a 5 Likert scale with 1 = not at all, 3 = neutral, 
and 5 = very much. The scale was developed and used in research for evaluation of the 
feasibility for autistic adults (Rischel et. al, 2022). 
Dialectical Behavior Therapy- Ways of Coping Checklist (DBT-WCCL) is a 59 item self-rapport 
questionnaire that Assesses both positive and negative methods of coping with stressful 
situations including problem-focus, seeking social support, blaming self, blaming others, 
wishful thinking, and avoidance as well as DBT skills use on 4-point likert scale: 0 = Never 
Used, 1= Rarely Used, 2= Sometimes Used, 3 = Regularly Used. The questionnaire is divided 
into 2 subscales: 1) DBT skills subscale that consists of Nine items represent emotion regulation 
skills, seven represent interpersonal effectiveness skills, five depict mindfulness skills, 19 
represent crisis survival skills, two depict reality acceptance skills (0-114). and 2) Dysfunctional 
Coping Subscale that consist of 17 items referring to dysfunctional behavior in general along 
with items referring more specifically to blaming others (0-63). (Neacsiu et al., 2010) 

 
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Qualitative interview guide – DBT skills training ASD (see attached Interview guide), focusing 
on the participatns goals, hinders and resourses, and how they expereinced the treatment 
intervetions in relation to accieving these goals.  
Adherence  
Statistical analysis 
To assess if adding DBT skills to standard treatment is relevant, feasible, accepted and potential 
benefits descriptive statistics will be provided. Descriptive statistics for demographic and 
psychological factors measured on a continuous scale will be reported in terms of mean or 
median value with appropriate measure on spread (standard deviation or quartiles) whereas the 
distribution of categorical factors will be reported in terms of proportions and percentages.  
Ethics 
Attending study is voluntary and requires an informed consent. Refusing participation in the 
study will not affect patient’s access to other treatment. The participation is time consuming and 
demanding for the patient. There are number of potential benefits for participants in this project 
such as access to treatment that can lead to symptom reduction, less suffering, and greater 
quality of life. Benefits from participation are supposed to outweighs potential discomfort.  
Data Protection: All data will be stored according to established protocols on data protection of 
More & Romsdal Health Trust. The data will be stored 5 years after the end of the project. The 
information will be stored in a de-identified manner. The scoring key will be stored separately in 
a locked cabinet at the outpatient at the DBT clinic ROBUST in Molde and only the authors 
(JV, RH and IG) will have access to it. All statistical analysis and use of data collected in this 
project will be done on a group level.  
Strength and limitations  

 
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Strength: This is a feasibility study in naturalistic treatment, making the results generalizable. 
The result of the study gives relevant information in a population that is often excluded from 
studies because of ASD diagnosis.  
Limitations: With a lack of a randomized control group, one cannot measure the direct effect of 
the intervention.  
Future research: If the intervention fits the progression criteria and proves to be relevant, 
feasible, acceptable, and of potential benefit for the patients, the future aim is to conduct a 
Randomized Control Trial (RCT) on the effect of DBT skills training for autistic adults with 
difficulties in emotion regulation. 
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