Autistic Therapy: 8 Things to Consider
Autistic Therapy
Being an Autistic person seeking therapy is often confusing, challenging, and frustrating. Presently, most models therapist use in the United States are not inclusive of diverse neurotypes. These models don’t take into consideration our needs and how we process our inner and outer worlds. Therefore, Autists are often made to feel like therapy isn’t for us. Which couldn’t be further from the truth! Neurodivergent people generally experience higher rates of mental health and substance-related issues than allistic people. Therefore, learning how to work with Autistic clients is vital.
In this article, I will explain my experience—as an Autist both seeking and providing therapy—and provide you with some pointers on how I believe private therapy practices can be improved to be inclusive of Autistic people. Of course, this information comes from my personal experience as an Autist who has received therapy and as a therapist who has provided therapy to neurodivergent people. These pointers aren’t complete and may not apply to every Autistic person you work with.
Failing at Therapy—My Experience
Over the years, I've worked with a handful of therapists, school counselors, and spiritual directors. I have found many of them helpful, and some helped me navigate some very dark terrain. I am grateful for them. However, I was totally masking most of the time. Often, I’d go to therapy and be "performative." I felt awkward with many of their questions; it often felt intrusive, at times, I didn't know what to say and was frustrated the therapist just sat there (attempting to make eye contact!). Also, the insistence on using emotional words to describe my inner world just left me feeling incompetent and confused. Cognitively, I knew my therapist was supposed to be someone I felt comfortable being vulnerable and authentic with, and yet I was confused by the fact that, in reality, I would become very self-preserving and performative in relation to my therapist.
Working with some clinicians was simply painful. I'd develop sophisticated strategies to either a) get the therapist talking or b) try to come up with monologues to fill the time. I suspect a number of neurodivergent people leave therapy after a few sessions a) feeling incompetent (because they've been asked to do things that do not come as naturally for them) and b) believing therapy isn't helpful for them. This is unfortunate for a myriad of reasons, from the internalization to the co-occurring mental health and substance issues that often come along for the ride when neurodiversity is in the picture.
Finding the Right Fit for Autistic Therapy
I've been working with a psychoanalytic psychotherapist for the last three years. Instantly, I knew I liked him when he started our second session (i.e., first real session) with, "what's on your mind?". I was shocked by how much of a difference this simple question made. While I didn't consciously realize it, I was bracing for the horrid "how are you?” question.
This is what my Autistic brain does when someone asks how I am:
Are you asking me how I feel in this moment, how I felt this morning when my kids were fighting, how I felt this week globally? How I'm doing in this season of life generally? Are you asking how I feel when I'm in a special interest or how I feel when I'm doing life tasks? There are so many different feelings happening, and they all depend on context, so how do I possibly synthesize this into one concise sentence?! (Remember expanding on details tend to be easier for us than summarizing and synthesizing).
When my therapist asked what was on my mind, first, there was a huge sigh of relief that I didn't have to try to navigate the terrain of "How am I", but secondly, I couldn't stop talking! Typically, I am shy, reserved, and quiet when the focus is on me, but I found myself talking incessantly. I found myself being open and authentic in front of another human—a rare experience for me.
Later, when I brought in existential philosophy and theology texts which had moved me that week, and straight-up read segments out loud, he didn't flinch. He took it in with curiosity and helped me connect the dots of the meaning of the text to the meaning of my life/experience/history. He came alongside me in my pattern finding and helped me slow down long enough to move into my experience.
When I brought in essays I had written where I interwove theology, philosophy, psychology, and subjectivity, he let me read them to him. He was patient and curious and let me introduce him to my inner landscape the way I needed to--through my very active, emotion-drenched mind.
A terrible stereotype about Autists is that we don't have emotions/we're robotic. Rather, I believe it's more accurate to say; we just don't express emotions in the same way neurotypicals tend to. We don't divide: our emotions and context, our emotions and ideas; they are all integrated and intertwined. Personally, I've always been confused by a lot of “emotion talk” in the sense that it feels like a false dichotomy to talk about ideas vs. emotions. To me, ideas are emotions. I am most alive, empowered, passionate, moved, or angry when I'm in my ideas expressing these things. When I talk about my ideas, I am in a deeply emotional space. When I talk about ideas, I am sharing of myself. Sure, I won't be the client using feeling words (sad, happy, mad, fear, irritated) to express myself, but I will tell you a story or an idea.
Often, I see the same trend in my neurodivergent clients. We talk about ideas, make connections and find patterns, and it's deeply emotional even if we never utter emotion words. Freud's idea that intellectualizing is a psychological defense has done us Autists harm in this way. Can intellectualizing be a psychological defense—absolutely. But it can also be a rich way of introducing you to our inner landscape. We are inviting you into our rich, emotionally fused inner world. It may not look traditional, but it is deeply authentic.
Considerations for Neurotypical Therapists working with Neurodivergent Clients
If you are a therapist, there are many considerations to consider if you want to be inclusive of all neurotypes. For Autistic people, there are several ways that you can help us navigate and unmask in our therapy sessions with you.
Why it’s Important
There are several ways therapists can become more inclusive of neurodivergent clients. But first, here’s why it’s important—according to some research, approximately 20% of the population is neurodivergent. Many of us Autists experience more struggle and mental health concerns due to the stress of navigating a neurotypical world. So, there are likely more neurodivergent clients on your caseload than you realize! Unfortunately, a lot of our training doesn't prepare us to be inclusive in our practices.
As therapists, we are trained in how to work with the neurotypical inner landscape. We learn words, methods, and interventions that speak the language of neurotypical expression and experience. This mode of therapy doesn’t translate well to many neurodivergent folks. Similarly, when I’ve talked with colleagues with diverse ethnic identities, many of them talk about needing to re-train and teach themselves in order to learn how to work with their non-white clients. I found it poignant when reading Pilar Hernandez's work, “Intersectionality, Power, and Relational Safety” where she explores the pressure that BIPOC therapists in training experience as they essentially have to learn how to do two different kinds of therapy (therapy with white folks and therapy with BIPOC).
This idea of needing to go outside of traditional training to learn how to practice psychology with clients outside of the dominant culture resonates. I feel as if I am in unexplored terrain as I figure out what it looks like to work with neurodivergent clients. As a neurodivergent person myself, I draw a lot on instinct in this process. While my training provides a compass, hiking boots, and a general (but outdated) map, I am intuitively moving my way through the undeveloped forest, totally “bushwacking” my way to get there (to use a backpacking metaphor). Sometimes it’s magic; other times, I totally trip and fall and bumble my way through it.
List of Considerations
So while it’s not an exhaustive list, here are some thoughts I have on how to become a more neuro-inclusive therapist. These are based on my experiences as a client, and my experience working with numerous neurodivergent folks. It’s based on hearing them talk about past (failed) therapy attempts and based on me intuitively figuring out what works for them. But also, it’s based on my perspective as an Autist that has a decent dose of alexithymia (inability to identify and describe ones emotional landscape), and so many of these may not apply to Autists who are more openly expressive. (To be clear: not all neurodivergent people are Autistic, so many of these strategies will not apply in the same way to your ADHD, Bipolar, etc. clients.).
Please stop asking us where we feel it in our body: it feels intrusive AF. Yes, yes, I know it's important to help us understand the body-mind connection and increase awareness around bodily sensations. If you sense your client needs help with this, provide education around it first. We likely need to understand WHY it's important. If you explain the context (and the science) behind why this is important, you'll get more buy-in.
Similarly, stop asking us how we feel about everything. This will mostly make us feel incompetent, but also, feelings are so complex. Instead of starting a session with "how are you doing" or "how are you feeling" consider asking, "What's on your mind?", or "Where would you like to dive in today?" or, "Tell me about something significant that happened this week."
Help us learn the rules of therapy. Especially for us high-maskers, we are hypervigilant about figuring out the rules and norms guiding any given social interaction. Therapy is like a mysterious box; we don't know the rules! And that's terribly stressful and uncertain for us. When we go to therapists who don't provide a frame and teach us the rules or guide us by asking questions, this is very painful. This is a lot of uncertainty you are asking us to hold. Consider being more "directive" with us, particularly in the beginning while we're figuring out the rules of engagement.
Be curious and patient. It will probably take us a while to figure out how to introduce you to our inner world. Questions help. Some of you have been trained to sit in silence until the client talks—please don't do that to us! It's excruciating to feel the expectations of the other but not understand the rules/what is expected of us. Help us out, ask us questions. Draw us out. Talk about a shared interest with us, or get us talking about one of our special interests. If you get us talking about a special interest, you will learn a lot about us. Then you get to be the pattern finder and help us connect meaning from our special interest to other areas of our life. And then we're off creating metaphors together, and its super fun.
Re-consider your rules around self-disclosure. As therapists, we are trained to be very careful with self-disclosure (which is good and important!), but also should be treated contextually. Also, there is this technique a lot of therapists use; when the client asks a question, you turn it back on them. Such as:
Client: "Are you a Cubs fan?"
Therapist: "I wonder what it would mean to you if I was a cubs fan?"
Okay, obviously, clients aren't talking about Cubs that often in therapy (that part was a joke), but you get the point. Here's the thing. When we ask questions, often, what we're asking for is psychological safety. We live in a perpetual state of micro mis-attunements from the world, and many of us don't trust our perception of reality because of this. I believe some of the deepest, most meaningful therapeutic work for Autistic people happens in the in-between space (i.e., interpersonal or intersubjective therapy). Many of us are constantly attempting to de-code what people actually mean. Authentically talking with another human being about what is occurring in the in-between is likely the most healing form of psychotherapy for us. (Yes, I know, all the "experts" say CBT is the best approach, I disagree—especially when working with high-masking Autistic people).
6. Find the meaning in the story. If you ask us how we feel about something, we likely will explain it to you or tell you a story. Don't dismiss this as just "too much content." Listen, find the gold and meaning within the story. (Also, this is good practice when working with clients from high contexts cultures, so it's a good inclusive practice in general).
7. Engage in pattern-finding. Many of us love pattern-finding and are good at it. When you help us connect one experience to something we've discussed three sessions ago or to another area of our life, this is powerful and helps us grow and gain insight. It likely also helps us gain trust and faith in you as a therapist.
8. Diagnose us. Okay, that's an idea for another post; I won't get into it here. But seriously, good therapy helps people understand their experience of the world—good therapy helps a person wrap a narrative around their experience. Understanding our neurotype can be a huge piece of understanding our narrative. If you diagnose personality disorders, complex PTSD, and ADHD without flinching, consider why you aren't comfortable diagnosing autism. It's a neurotype, not a death sentence. Don't fear the diagnosis.
Conclusion
Today, the popular therapy models most therapists in the United States use are outdated and exclusive to many marginalized people. Specifically, these models are exclusive of Autists and other neurodivergent people. Neurodivergents make up about 20% of the population, and we tend to experience higher rates of mental health and substance abuse-related struggles due to the stress of navigating a neurotypical word. Therefore, as mental health therapists, it’s important for us to do what we can in our practices to make therapy more accessible to Autists. By making these changes and continuously learning about neurodivergences, we are actively changing these outdated therapy models to be more inclusive.
