Clinicians: Why and How to bring autism into the conversation
Welcome to part 1 of a 3-part series designed for clinicians who want to become more comfortable identifying and working with autistic adults.
In this post I discuss rationale for therapists to bring autism to light when they see traits - and some tips for a skillful conversation.
Autistic traits could be Right in front of you, but you need to know how to look
Let’s suppose you are a trauma-focused clinician with basic training in autism (meaning very little), and you have a client with acute trauma. Let’s say this client is not responding as expected to your modality, and also has a collection of features that are confusing, but are starting to come together.
The client may have trouble naming their feelings or locating them physically. They have a number of clustered physical ailments that doctors are challenged with diagnosing - GI issues, autoimmune reactions, skin issues. Perhaps they also pick their skin or twirl or pull their hair, or fidget a lot during session. They may avoid commitments or prepare for them with extreme effort. Perhaps under stress they find it difficult to speak. Maybe they have a vivid imagination and a lot of intrusive images. They have a busy mind that is almost always meta-analyzing what’s happening. They may avert their eyes, slouch, or bump into things. They cover their ears when the construction sounds start outside. They are exhausted.
If this client is gainfully employed, lives independently, and has other diagnoses (enter, bipolar disorder, depression, generalized anxiety, panic disorder, OCD, a personality disorder) are you comfortable talking with them about the possibility that autism is underlying some of their experiences? If so, how would you do it? If not, why not?
Why therapists don’t talk about autism
It’s understandable to feel uncertain or apprehensive about bringing autism into the conversation. Therapists often worry about:
Misdiagnosing: A complex presentation means a number of judgment calls and many ways you could be wrong. This is reinforced by the restrictions on who can diagnose Autism. In graduate school, masters level clinicians are trained to be very hands-off on identifying and naming autism.
Lack of knowledge: Therapists receive little training in autism in graduate school and over the course of most associateships. For those looking to learn more, it can be hard to discern, from information available, what is credible and affirming, and what is not.
A negative client response: Therapists worry about alienating the client. The client is exposed to all the same stigma and misinformation that therapists are exposed to, plus family narratives, adverse experiences, etc. There’s a chance that mentioning autism could lead a client to feel insulted or misunderstood. They may feel afraid or confused.
Fear of saying it wrong: Clinicians want to be affirming and helpful, and there are cautionary tales about using the wrong terms, or inadvertently reinforcing ablism. You may sense that you have a bias but be unsure how to keep it out of the conversation.
Worries about what this means: Clinicians may be two steps ahead, thinking - if this is autism, where does that leave me? Am I prepared to rework my treatment plan? What if I’m no longer qualified to help?
Masking: Many autistic people have learned, some from a very young age, that they have to hide their preferences, or how they move, or change how they speak to get along with others or avoid punishment. Some clients mask strategically, and many others are not even aware that they are masking their autistic traits.
Bias: stereotypes about autistic people may lead clinicians to disregard someone’s traits because a client is employed or married, have friends, have kids, speak in engaging ways, seek help, etc. Even if these biases are unconscious, they can affect what possibilities we entertain. Autistic people are everywhere, with a wide range of dynamic abilities and challenges.
As mental health professionals, we know that remaining in the dark or avoiding difficult conversations doesn’t support our clients’ growth.
Benefits of identifying autistic traits
Addressing the possibility of autism is a key factor in supportive and effective treatment. Many autistic people, who were once unidentified, report missing it themselves due to the inference (or being told repeatedly) that they were just not trying hard enough. They may assume their challenges are universal, and everyone else is handling the same challenges more skillfully. Many late-identified autistic people explain that autism identification was a process of shedding a lifetime of shame and finally reworking their life so that it was manageable and joyful for them. Here are some additional benefits to identifying autism:
Create a more coherent narrative for clients who may have been diagnosed with several different mental health disorders, or are facing challenges that previously had no name.
Improve treatment planning: You can support the client with self-discovery, tailor emotional regulation techniques, keep learning style and sensory experience in mind with your methods, or refer out to a therapist who has more expertise.
Improve trust: You are seeing something that others have overlooked and taking their complaints seriously.
Preparing for a thoughtful discussion about autism
If you’re feeling unsure about how to handle this situation, you don’t have to do it alone. There are many clinicians out there who are autistic themselves, are trained to diagnose autism, and/or are regularly successful working with autistic people. You can reach out for consultation, join a group, or take a webinar before proceeding. You may also wish to talk to a trusted friend or mentor about your fear, including any potential biases that are arising at the edge of your awareness.
When you are ready to approach the autism topic, here are a few things to keep in mind:
Build trust first: Establish a safe, nonjudgmental space to the point where the client has begun to share some of their internal experiences.
Listen to how the client frames their challenges: Do they cluster certain challenges together? Are there certain characteristics of theirs that tend to confuse them?
Listen for autistic strengths: For example, autistic people are often persistent, courageous, good friends, full of integrity, funny, gifted, and great with recognizing patterns.
Ask open-ended questions: They may already have an inkling that autism could be part of the picture. Exploratory questions can help you assess - for example, “How do you make sense of that experience?” or “Do you know others who share that struggle?”
Be transparent and direct: It’s important not to overly pad what you are trying to say - that can create anxiety or the sense that autism is toxic. You can try: “I’ve been thinking about some of the challenges you’ve shared and what they may have in common. For example (name a few examples of what they’ve reported). Have you ever considered autism as an explanation? … Would you be open to exploring that idea?
Emphasize their internal experience: Many autistic people have difficulty with the experience of being perceived. With that in mind, don’t lean heavily on behavioral observations, (ie, posture, eye contact, speech style) since clients may have an automatic fear response or feel judged or “outed.” It is likely to feel safer to a client if you lean more on the client’s internal experience as they describe it, for example, feeling like they need a translator in social situations or struggling to get started on care tasks that to them seem easy for others.
Receive their response as it is: This isn’t the time to convince the client or push a certain agenda. If your client is upset, you can let them know you hope to repair the misunderstanding. In my experience, identification with autism doesn’t often happen in its first mention. Some clients need to approach the topic in the future on their own terms, after thinking about it, researching, and crowdsourcing.
Keep the DSM out of it: The DSM does not use language that is affirming, and is not concerned with the lived experience or way of thinking that proceeds the stress behaviors listed as symptoms. There is a place for the DSM in the diagnostic process and establishing medical eligibility, but it is otherwise not a useful resource, especially for initial conversations. If you’d like to take a look at what language not to use, give the DSM a fresh gander.
Pivot your language: if a client has expressed a bias or aversion to the word autism, you can still discuss the client’s challenges in the context of neurology or patterns, and support the acceptance and identity development process. Although words matter, and I recommend modeling and normalizing the term autism, the client is the person in the driver’s seat here.
Discussing autism openly and as non-anxiously as possible is a way of signaling that this is a safe topic for them to engage you in. You don’t have to have all the answers to be a thoughtful listener and help your client better understand themselves and access the treatment process.
Opening the door to autism may be the only way your client sees it as a possibility - both as one they can consider, and as one they can disclose to you. Remember that we aren’t just discussing autism the diagnosis, but also autistic the identity, and people need to feel a certain level of safety and lack of judgment to disclose it. You can be a partner in acceptance and deeper self-understanding.
