From plan to Action: Building autism affirming practices in therapy (part 3/3)
If you haven’t read parts 1 and 2 yet, start here:
In a previous post, I wrote about why it matters to bring autistic traits and experiences to light, and what happens when autism remains unrecognized. In part 2 we talked about shifting your lens and appreciating the cultural context around autism. More therapists are starting to recognize autistic traits in their clients—and recognition is just the start to many steps that follow. I worked hard to narrow down the considerations for adapting therapy into this small container - but know that there are excellent books on this topic. This is just a brief summary.
Below are some considerations and first steps—grounded in research and lived experience—that can make your therapy more accessible, affirming, and effective.
Adjusting the Frame of therapy for autistic adults
When I was in graduate school (15 years ago), autism was discussed as a disorder to treat - as such, if you weren’t providing a behavioral treatment aimed at addressing DSM-V autism symptoms, you weren’t qualified. Autism was only talked about as a childhood condition - as if the really great behavior treatment out of our scope of practice as MFTs “cured” autism, and, lo and behold, there were no autistic adults. Sadly, I have heard that graduate schools haven’t adjusted the curriculum much. Although that miseducation never sit right with me, now that I spend most of my time with autistic adults, I can really see how much the “treat the autism” approach misses and harms autistic people. Not only does it not meaningfully support autistic people with what they actually want help with, but that approach can be dehumanizing by requesting, if not demanding, that autistic people mask or “cure” their very way of being.
The good news is, as a clinician, you are so much more qualified to support autistic adults than the DSM and outdated graduate courses would have you think. Updating your information and adjusting your approach is very doable.
Lesson number one here is to be very certain that autistic people are people. They come to therapy for help with their mental health. Autistic mental health has so much in common with everyone else’s, even as there are some key patterns to the autistic lived experience and expression of mental health that you should know.
Here are some of the most common mental health support requests I get from autistic people seeking services:
Help with anxiety, racing thoughts, OCD, rumination, overthinking
Help with a body-focused repetitive behavior, like skin-picking
Help with depression, sometimes better understood as burnout
Help finding and developing friendships, and feeling more satisfied in partnerships.
Help with identity, increasing positive activities and interests, and authentic self-expression
Help identifying and communicating needs and implementing boundaries
Help managing pain and confusing health conditions
Help with executive functioning and managing the difficulty of care tasks
Help with self-acceptance and self-compassion
Support with grief
Help navigating unsupportive, hostile or oppressive environments
Help with the side effects of masking, and determining when it is and isn’t worth the effort
Healing trauma and managing post-traumatic responses
Creating a plan to avoid sensory meltdowns and improve sensory regulation
Dealing with factors of disability, such as limited access to meaningful work, navigating resources, financial stress, limited energy
Working well with Autistic Clients
Having a sense of the mental health needs of the autistic client in front of you - and supporting those needs well - very likely will require some strategic shifts on your part in how you conduct therapy and how you help equip your client for the world as they experience it.
Communication
I would argue that communication is the most essential ingredient of psychotherapy, so it’s time to get really good at understanding autistic communication. Consider for a moment, that, to survive, autistic people have had to be extremely observant and reflective about allistic communication. As much work as that is, autistic people can rightfully be very frustrated when allistic people aren’t equally curious and full of effort regarding autistic communication.
Many autistic people prefer clear, direct, often literal language. They may not read tone or facial expressions the same way you do, and may have spent years being blamed for being the problem in two-way communication mishaps. Therapy can be an environment where the client can discover more deeply how they prefer to communicate, and get some assistance building communication bridges with people in their lives. That starts with tending to the communication between you and the client.
Therapy adjustments:
Be literal and explicit. Avoid colloquialisms that can be confusing - or, depending on your client’s sense of humor, you can mix them, play with them, and make light of them.
Get meta - notice how your client likes to communicate and show them that you notice. Get curious, compliment them, notice any differences that arise and any ways they are making you think about your own communication.
Be patient and warm with the client’s many questions - autistic clients need a level of specificity that you might not expect in order to feel grounded and clear
If you and your client both like using metaphors, they can be an amazing, visceral short cut for describing complex experiences.
Don’t assume shared meaning. Ask for clarification and give it.
Recognize that “flat affect” isn’t a sign of disengagement or depression.
As Damian Milton (2012) wrote in his work on the double empathy problem, communication breakdowns are mutual. The responsibility to repair them goes both ways.
Assistance with communication in the real world:
Help the client identify communication differences between themself and their important people
Frame communication difference as a shared problem
Validate the labor of communication and building bridges, and offer encouragement
Support the client with building ready language to express their new understanding about themself
Slow the Pace—Processing Takes Time
Autistic clients may need more time to process verbal information, especially in emotionally intense moments. I know that if I’ve been discussing something particularly distressing with a client, they may struggle to remember any of that work (at least, verbally). Many have internalized a belief that they must keep up or perform, and so you might see gestures of understanding without the corresponding comprehension.
Instead, try:
Slowing your cadence.
Building in pauses.
Offering written recaps or summaries.
These changes don’t reflect a lack of ability—they respect a different processing style. And they often reduce anxiety in session.
Processing in the world:
Help the client identify environments where there is a mismatch of pace
Help the client identify potential support and take steps towards building or accessing it.
Help the client build sensory tools and self-advocacy approaches that can support navigating fast-pasted environments.
Be Mindful of Masking and Emotional Expression
Many autistic clients come to therapy fluent in masking. They’ve learned to suppress their natural communication, hide sensory distress, and overperform social cues to avoid being misunderstood or rejected.
In therapy, that often looks like:
Nodding even when confused.
Smiling when overwhelmed.
Performing insight they’re not actually feeling.
Therapists can gently invite authenticity by affirming all forms of expression—including silence, pacing, monotone speech, disagreement or eye contact avoidance. Instead of reading between the lines, ask what’s happening directly.
When clients do express their emotions, they may surprise themselves or you. Emotions can come on quickly, feel very intense, and lead to shut down or dissociation. Some clients have very intense thoughts or language at the peak of their feelings. Clients may need support with grounding, bringing in a sensory support, and learning from that experience about their feelings and nervous system. You can then approach feelings with more containment, in smaller doses, or with more support.
Understand Autistic Burnout
Autistic burnout is a real and pervasive experience, especially for clients who have spent years trying to survive in neuronormative systems. It often looks like exhaustion, shutdown, loss of functioning, or difficulty accessing coping.
Signs of autistic burnout may include:
Reduced executive functioning
Difficulty with speech or self-care
Emotional numbness or hypersensitivity
Feeling disconnected from one’s own preferences or identity
Therapy adaptations:
Reduce pressure to perform or “work” on goals.
Shift focus toward rest, sensory regulation, and identity reclamation.
Explore what led to burnout: Is the client overextending? Masking heavily at work? Being misunderstood by family?
See here for a definition of autistic burnout and here for an e-book on burnout.
Encourage and Support Self-Advocacy
Many autistic adults have never been given language to describe their needs, let alone permission to assert them. Therapy can be a space to build both.
How to support:
Validate when you or the client notice discomfort, even if they can’t explain it.
Collaborate on simple self-advocacy scripts like:
“I need a break.”
“I’m overwhelmed.”
“I prefer not to make eye contact when talking.”Name advocacy as a strength, not a demand.
Autistic Self Advocacy Network is an example of what autistic self-advocacy looks and sounds like.
Beware Dismissiveness
You may not realize how common dismissiveness is and how easily it can come out. Dismissiveness erodes the goal of self-advocacy and sounds like:
“Why don’t you just…”
“When that happens to me, I just…”
“It wouldn’t be that hard to just…”
“You’re overthinking it”
Frequent interruption without rationale and agreement
Advice before exploration
Two problems with dismissiveness messages:
The statements sit atop a mountain of dismissiveness and are very triggering, so you may be now facing a client in dysregulation, or may trigger shutdown or masking.
They contradict the message that you want to be collaborative, because now any feedback to you can be dismissed too.
Make the Therapy Space More Accessible
Accessibility has a huge impact on a person’s ability to learn and leave your session resourced rather than depleted. Some small shifts go a long way:
Offer virtual sessions if in-person space is overwhelming.
Invite clients to stim, use fidgets, or wear sunglasses/headphones.
Avoid sensory triggers (like flickering lights or overpowering scents).
Check if the client prefers visual presentations of information
Check frequently for understanding and be willing to simplify or expand on what you are saying
This list can be built upon collaboratively with the client. Start by not assuming that your space is accessible from a sensory and learning perspective.
When To refer out
After you’ve put certain efforts in place, it is still possible that you may need to refer out. Referral to a practitioner more familiar with autism may be what’s best if:
Your client’s symptoms aren’t improving
You aren’t able to build the skills you need in the time that the client needs them
You are having trouble communicating with the client despite efforts to bridge
You and the client have a mismatch in how you prefer to work.
The client is requesting an autistic provider or specialist
When you refer out, I recommend you be direct and kind. There is no expectation that every clinician be a fit for every client. Let the client know that [something specific they are wanting help with] is a mismatch with your tools. Or let them know that you expect they might make more progress with someone more familiar with their primary mental health concerns. Be aware that a referral can be interpreted as rejection, and convey genuine appreciation of the client. But don’t be so afraid of the client’s fear or potential reaction that you aren’t honest with them and ethical about client care. Avoid expressing hopelessness or your own insecurities, and stick with what’s observable and a perspective that there are many things yet to try.
Final Thoughts
I hope to see a day when competence and confidence working with autistic clients is as standard for mental health clinicians as working with people who have depression and anxiety. Once we make some fundamental shifts, regard autistic people respectfully, wake up to the neuronormative standards we all live in, and willingly collaborate, the details will come together. Autistic bodies and nervous systems can be complicated, but so much confusion about autism is rooted in misunderstanding and miseducation, not unsolvable problems. Autism is not an epidemic or disease like COVID or the measles. It’s a legitimate way of being that can be traced back to many of our early ancestors.
Thank you for being here, and I hope you enjoy putting these ideas into action. If you need any support along the way, I am here to help. Email me if you’d like to set up a consultation: jen@justrighttherapy.com
I have an ongoing monthly group that helps clinicians put their plans into action. You can sign up here: https://justrighttherapy.com/workshopsandconsultationgroups/p/incorporatingautism
