From Awareness to Plan: Incorporating Autism into Therapy (part 2/3)
This is part 2 of a 3 part series for clinicians who are not accustomed to supporting late identified autistic adult clients but would like to build their competence. See part 1, Clinicians: Why and How to bring autism into the conversation
In this post, I will cover:
First steps after a client identifies and resonates with autism as an explanation for their challenges
Ways you can increase your knowledge about autism as a physical and cultural experience (not just as a set of “disordered traits”)
The cultural context of autism identification
Some perspective shifts that autism invites us to make
Recognition Is Just the Beginning
If you’ve been working on recognizing some lesser known but consistent patterns that might indicate autism (beyond just the DSM-V criteria), and having thoughtful conversations with your client, then you’ve been doing hard work that many clinicians don’t! I am here to encourage you to take the next step.
Recognition of the potential of autism starts a lengthy process of more deeply understanding your client’s strengths and challenges and how to adapt therapy for their needs.
The client begins an identity development process and reshapes structures and expectations in their life, a journey that can be very complex, and benefits from a well-informed guide.
Screening for Autism
If you haven’t already, now is a good time to look into descriptions of autism written by autistic people. Autistic people can be brilliant with pattern recognition and spotting their neurokin. Autistic people tend to be concerned with and aware of the internal experience of autistic people, as well as the science of how autistic neurology works. For example, check out:
https://reframing-autism-s-school.teachable.com/p/autism-essentials
https://neurodivergentinsights.com/
https://aane.org/services-programs/training-education/
https://autisticadvocacy.org/about-asan/about-autism/
…And so much more!!
Masters-level clinicians are qualified to diagnose conditions in the DSM-V, but depending on your state and your training, your diagnosis of autism may not be valid in consideration of accommodations and state resources.
Masters clinicians can screen for autism, just like any person suspecting they are autistic can screen themselves. There are free screeners available here: https://embrace-autism.com/
You may wish to have the client check out these questionnaires on their own, or you can do them together. Instructions for interpretation are in the screeners.
If screening is suggestive of autism, your client has the option to get psychological testing to confirm diagnosis. This is a process that takes time and money, and may result in autism being on the person’s health record (not to mention, there are states that mandate registration). It may be useful to pursue diagnosis if:
The client is in need of significant accommodation at school or work.
The client wants to apply for disability benefits.
The client needs more specialized health or mental health care, or mental health symptoms are severe.
Some clients want the diagnosis as confirmation.
Cautions for diagnosis:
There’s no way to be completely sure that a record of diagnosis won’t at some point disadvantage a client.
Diagnosis has barriers such as cost and time investment.
The autistic community is generally open-armed to new members, and highly likely to accept self-diagnosis. People who are feeling socially insecure about being self-identified may have doubts that can be resolved through exploration.
Clients may prefer a cultural understanding of autism over a medical one.
Autism awareness and acceptance as a political and cultural movement
When we are open to seeing autism and aware of some of the more subtle presentations, we may start to see it much more frequently than we’d expect. This upends some of our assumptions, such as assumptions about who is autistic and prevalence of autism, and upending assumptions can trigger fear and cognitive dissonance. It can also liberate people from constraints and limitations.
Autism identification is happening within a cultural context. Some of that context includes:
Benefiting from a number of civil rights movements, including the disability movement, which have paved the way for visibility and self-advocacy
Wide availability of information due to technology advances have made autism less mysterious.
As more autistic people are identified, and many of them receive some of the support they need, more of them are surviving, achieving professional positions, and in better position to self-advocate.
Autistic people are collecting, talking, and coordinating their efforts.
Autistic people are now actively and openly involved in research, diagnosis, and support.
Research is revealing some of the underlying neurology of autism, meaning we do not need to rely solely on stress behaviors described in the DSM to identify it.
Autistic health is extremely responsive to environmental conditions. Autistic burnout, for example, generally involves stress, excess demands, or neglect of needs to trigger conditions related to immune responses. It follows that increases in environmental stressors or ill health of the environment would lead to more autistic stress symptoms.
Demands on parents in the US, alongside decreased social support, is making it all but impossible for some middle age adults to mask their challenges.
Understanding of genetics has led many parents of identified children to also be identified.
It’s important to consider the cultural context in which our therapy sessions take place. Regardless of how much your client is aware of or wants to talk about these things, it is good to have a wide perspective. Let’s think critically about why some people may be afraid to talk about autism, or be threatened by the increase in autism identification.
They have a pre-existing agenda and autism is an attention grabbing issue to attach their agenda to.
Accommodating autistic people turns the table on accommodation. Allistic (not autistic) people do not realize the amount of accommodation that autistic people do for allistic people, in order to not be shamed, attacked, or excluded. Therefore allistic people may see honoring autistic needs as a burden rather than a natural rebalancing.
Leaders of under-resourced systems with heavy administrative loads will recognize that “If I give this accommodation, I might have to accomodate everyone.” That may or may not be costly - but what it triggers is wider questioning of the system and impetus for system change. Many of our public systems are not designed to be limber, so the request for materially simple changes can be amplified as enormous tasks.
Let’s think about just a few potential benefits to listening to autistic voices more widely.
More advances in treating complex health conditions.
More action towards addressing dysfunction and/or stagnation in systems.
More urgency to address our global and environmental predicaments.
More innovation as different types of thinkers become better at collaboration.
More humane working conditions for everyone.
Build your knowledge
It’s important to start bringing knowledge to the table with your client. Although the client is the author of their specific experience, expecting them to explain well-documented dynamics in autism is exhausting and takes from the time you could be providing support.
Find autistic voices speaking out - you can follow autistic voices on social media (Autistic_Lou, for example), listen to autistic podcasts (such as Neurodivergent Conversations), read books (such as Rediscovered) by autistic creators, and get involved with autistic-centered organizations (such as the AANE). This will give you a sense of experiences that autistic people have, and how they describe their experience, so you can be a skilled listener for these things.
Take a course or ask your organization to bring in a trainer
Prioritize trainers with lived experience
Look into trainings that work within your modality of therapy
Ask people in your network about their favorite training
Look at autistic advocacy groups and research groups. Notice what they are fighting for, and what research matters to autistic people. Join the cause where you can.
Network, buddy up, or join a consultation group: a place where you can safely learn, clarify misconceptions, and try things out is essential so that you aren’t just practicing on clients.
Note: there are a lot of different preferences in terms of how to use language about autism. Many therapists might falter in talking with their clients because they are afraid to say something wrong. While it is important that you aren’t saying hurtful things, don’t let the fear of language blunders keep you from having necessary conversations. If you make a language mistake, you can apologize, make a commitment to learn more, and move on. You can consider how often autistic people have to do this when they try and get their point accross to an allistic person.
Shifting your lens to incorporate autism
You will almost certainly have a formulation or opinions about the client’s symptoms that shift significantly once you consider autism as an explanation. Here are some dynamics to keep in mind:
Masking: People mask in therapy and out in the world to varying degrees. Autistic people aren’t the only people who mask, but because their natural way of communicating, moving and socializing is so regularly shamed and rejected, masking takes on a certain level of intensity and necessity. If your client has managed to go undetected as autistic for many years, you may be seeing only the tip of the iceberg in terms of how they feel, think, and move. It is common for an autistic person to mask automatically and not even know they are doing it. Masking interferes with regulation (such as stimming) and pursuing authentic interests and joys. Unmasking is a complex process that can feel extremely vulnerable. Knowing now that your client has had to mask to survive, how does that change how you see their symptoms?
Social dynamics: it may now make more sense what kind of people the client is drawn to, or some of the interpersonal challenges they have been expressing. Some patterns to keep in mind are - the experience of rejection from allistic people, cross-neurotype communication challenges, identifying neurodivergence in friends, and the impact of masking on connection.
Family of origin: Heritability is a well-researched explanation for autism. Because autism is expressed on such a large number of genes, this means that ancestors may not be apparently autistic, but may have several traits, or may have masked or created lives that accommodated autistic characteristics. Parents you once regarded through one lens (ie, as out of control, personality disordered, or collapsed) may have been unsupported with autistic challenges, or may have been masking autism, leading to burnout. Considering autism in the family line can have profound effects on perspective and family relationships.
Physical health: Your autistic client may have some conditions that commonly occur in autistic bodies and are very commonly misunderstood by doctors (thought the research is gradually getting traction). POTS, MCAS, hypermobility, migraines, allergies, sleep apnea, skin disorders, joint injuries, and GI issues are connected and common in autistic people, particularly following stressful periods. Clients are sometimes regarded as “just anxious” when they are actually in a great deal of pain with common conditions that remain mysterious to most doctors. Because of interoceptive differences, clients may have difficulty locating and articulating pain, or may have high sensitivity to pain that is not well understood by less sensitive people. Autistic people need others to believe them about their physical health symptoms, and help them effectively self-advocate.
Care tasks, sensory processing, and executive functioning: Difficulty with care tasks that may have been attributed to depression can now be considered more fully. The client may have trouble sequencing and initiating tasks, may have existential dread about the cyclical nature of care tasks, may feel burdened by standards of hygeine they don’t care about, or may have sensory issues that make ordinary tasks painful.
Rumination: If your client frequently ruminates and your approach hasn’t made much of a difference, it can be helpful to understand that autistic brains are prone to making highly detailed predictions in order to prepare themselves for actions in a world that is largely too intense and unpredictable for them. Communication in allistic spaces requires a huge amount of translation and interpretation. Considering these functions of rumination can unlock creativity in how you and your client help manage it (and consider that there are times that it may be useful).
Take a moment to consider any biases you may have about your client that were due to misunderstanding. Think about any of the times you were yourself impatient, or thought “this client just needs to try harder.” How is that perspective shifting?
You can keep learning
No clinician enters the field totally prepared to identify and treat everything. You get to be in progress.
Come back next week for part 3 of 3:
Reframing what treatment of autistic people means
Improving the treatment plan
Adjustments anyone can do to accommodate common autistic needs
When to consider referring out
