Autistic Adults
in Therapy
⧖ 43 minute read
Autism is not well understood by many healthcare workers. Frankly, it’s not that well understood by researchers yet either. Estimates put the global prevalence of autism at approximately 1%, which is 75 million people. However, these estimates vary, with a recent study reporting that approximately 2.21% of US adults are autistic, and recent CDC data indicates a rise in autism diagnoses, now affecting 1 in 36 children, up from 1 in 54 in 2016. Unfortunately, many autistic adults don’t get diagnosed until they’re in their 30s, 40s, and beyond.
Autism is not a disease to be cured; it is merely a difference in neurobiology. Many autistic people have been repeatedly told that they are ‘wrong’ for trying to live a bit differently and for having different needs. Throughout their lives, autistic adults who don’t yet know that they’re autistic often experience significant levels of isolation, confusion, suffering, shame, and trauma. Thus, much of the work of therapy for newly diagnosed adults may focus on self-acceptance and healing, though each person’s experience of autism is unique and therapy must respond to that.
I had been a psychologist for several years before found out that I’m autistic (at age 29); hopefully my unique perspective will be useful to share with my peers. This article explores some common autistic characteristics and relevant therapeutic concerns, and it is a starting point for therapists new to working with autistic adults. It’s organized to be a document you can reference.
Table of Contents
Click subtitles below to jump to various sections of this article
What is Autism?
The Mayo Clinic describes autism as “a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication. The disorder also includes limited and repetitive patterns of behavior. The term ‘spectrum’ in autism spectrum disorder refers to the wide range of symptoms and severity…Autism spectrum disorder begins in early childhood and eventually causes problems functioning in society.” That’s straightforward enough, though very medical and deficit-based. This definition has its limitations and does not fully capture the complexity and diversity of autistic experiences.
Therapists could review the DSM5-TR criteria for autism, which states things in a pathologizing manner. Consider reviewing several of the free autism screening tests, as these sometimes contextualize autistic characteristics more effectively than the DSM5-TR’s abstract explanation.
“Autism is such a heterogeneous disorder, so it’s highly likely that there are different causes for different kinds of ASD.” NIMH’s National Autism Coordinator Ann Wager. When therapists and doctors are ignorant about “autism spectrum disorder” (ASD), it’s common that they will rely on stereotypes, which perpetuates suffering and stigma. Even though I focus my clinical work on neurodivergence, I still have gaps in my knowledge and continue to learn about/from the autistic community.
The concept of “neurodiversity” offers an alternative perspective on autism, as well as conditions such as ADHD, dyslexia, Tourette's, and synesthesia, by celebrating differences in brain function and behaviour as natural expressions of human diversity rather than perceiving them as flawed or problematic. This viewpoint posits that neurodivergence is a normal aspect of human history and should be respected, understood, and supported rather than pathologized or deemed disordered. No cure is necessary. You could read more about this from many sources, such as the Autistic Self Advocacy Network or books such as Divergent Mind by Jenara Nerenberg and so on.
By adjusting the environment, reducing stigma, and valuing individual dignity, neurodivergent individuals can flourish in a diverse society. Familiarity with the "social model" of understanding autism and related ideas, including their advantages, disadvantages, and potential controversies, is essential for therapists to provide well-informed and comprehensive care (discussed on the wiki or here). Neurodivergence is often discussed in relation to the concept of being “neurotypical” (i.e., people whose brain development, processing, and behaviours are more standard or typical).
Therapists should understand how the medical world views autism, but hearing directly from autistic people is extremely important.
Many autistic adults have done a great job communicating about their experience, the autistic community, their needs, how best to form connections with them, how best to help, etc. This more direct advocacy is a fairly recent change, gaining more ground starting in approximately 2010. Most of the books I mention below were written by autistic people, some of whom are psychologists as well. There are many Youtube channels created by autistic people, such as Autism from the Inside and Yo Samdy Sam. The heightened advocacy and improved public comprehension of neurodivergence are highly beneficial, as they foster a broader societal understanding, reduce stigma, and promote acceptance and inclusivity for neurodivergent individuals and communities. Moreover, given the diverse manifestations of autism, self-identification can be challenging. Consequently, the availability of clear and accessible information proves invaluable in aiding self-awareness and recognition:
There are these two young fish swimming along, and they happen to meet an older fish swimming the other way, who nods at them and says, “Morning. How’s the water?” And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes, “What the hell is water?” ~Infinite Jest DFW
Like DFW’s water in the above parable, the experience of living with an aspect of your neurobiology or perception that is always present—in this case, autism—can leave a person unaware that they experience the world differently than other people. Imagine there was no test for colour-blindness; many people wouldn’t realize this simple difference of perception until at least adolescence, if not later. The way this concept relates to relationships is sometimes discussed as the ‘double empathy problem’.
When people are diagnosed during adulthood (i.e., late-diagnosed, or late-discovered), that can indicate that the client has functioned well enough that no one ensured the client saw a specialist earlier in life—that they can 'mask’ their autistic traits at times. It can also indicate a failure of the healthcare system, poor parenting, and so on. Alternatively, an individual's distinct characteristics or challenges may be recognized, but their root cause may be inaccurately attributed to another condition or concern. Potential misdiagnoses include depression, anxiety, borderline personality disorder, or bipolar disorder, among others. Consequently, the individual or their caregivers may seek therapy to address these perceived issues. However, obtaining effective support can prove challenging when the foundational understanding of the situation is incorrect. It’s also tragically common that due to fear, stigma, or shame, childhood caregivers sometimes choose to not seek assessment or any support, even refusing it when offered by schools or their doctor.
Regardless, this highlights a fascinating diagnostic criteria: symptoms may not become fully manifest until social demands exceed limited capacities. A common example: an adult will experience a change in their life that places additional responsibility on them, a responsibility or change that is particularly difficult to cope with due to being unaware of being autistic. Examples could be moving in with a romantic partner for the first time, going to university, starting a new type of work, getting their first dog as an adult, having their first child, having an ill parent move in with them, and so on. This new strain can seem unusually large to the person, so they start (or renew) their hunt for answers. Sometimes this journey leads to suspicions of neurodivergence and autism.
Living with undiagnosed (or unrecognized) autism is often substantially more challenging when compared to knowing you are autistic. When a person knows they are autistic, they
May experience less confusion, particularly related to identity and social situations
Can stop aggravating their sensory system continuously and accidentally
Can use this information to adjust their life (career, environment, etc) more effectively so it’s a better fit for them
Can use that information to (do the work to) better understand and accept themselves
For most adults, the discovery that they are neurodivergent is life changing, though the initial exploration can be upsetting or surreal. I hypothesize that the percent of people who seek therapy are more likely to be neurodiverse than a random sample of the population—because being neurodivergent can be quite challenging when most other people expect you to act neurotypically. Therapists should keep an open mind about late-diagnosed neurodivergence, and consider having clients use an autism screening test when appropriate. Keep in mind that autistic people quite often have co-occurring conditions (perhaps as many as 30%), with some of the more common ones being ADHD, anxiety, depression, and GI issues.
How Do I work with autistic clients?
Autistic people can have all the same difficulties with living, careers, and relationships as neurotypical people, and they may come to counselling for those things just like anyone else. Their challenges may or may not be related to neurodivergence.
Autistic people often learn to fit in socially by scrutinizing neurotypical people’s behaviour then trying to understand and mimic it—this is called “masking“. Some autistic people become skilled with this, though masking is exhausting, demoralizing, and inauthentic. This effective masking is often what leads neurotypical people to not believe someone is autistic or to describe them as high functioning. The majority of historical research on autism was done on males, so the minimal knowledge that most healthcare professionals have of autism is biased toward a stereotypically male expression of autism. Numerous misconceptions about autism persist among healthcare professionals, including beliefs that autistic individuals cannot exhibit emotional empathy, intelligence, traditional measures of success, engage in long-term romantic relationships, utilize humor, maintain eye contact (e.g., social masking), possess social skills, sustain employment, or attain advanced education. Unfortunately, these misconceptions continue to be invoked by some healthcare workers, such as certain psychiatrists, as reasons to refute an autism diagnosis, or refusing to assess for it and so on.
In work with autistic adults, if therapists attend to client preferences and client goals, then connection shouldn’t be unusually difficult, though at times it may seem unconventional. Some people click quickly and some don’t, some clients trust quickly and some don’t. A parallel could be to imagine how some clients with PTSD may take more time before they trust their therapist. Sometimes autism is relevant to the concern for counselling and sometimes it’s not, so I am careful to not over-identify with it in my autistic clients if it’s unrelated to the concern that brought them in to counselling. It’s similar, perhaps, to having a client who uses a wheelchair. You likely understand how using a wheelchair is irrelevant to many therapeutic concerns the client may have thus wouldn’t try to connect any and all therapeutic concerns back to the client’s wheelchair use. Consider, here. the kinds of frustration, exclusion, and discrimination that any potentially marginalized person or group may encounter.
Meeting your client where they’re at is particularly important with neurodivergent adults. As far as modalities or interventions that could be most useful: being patient, validating, safe, and accepting is more important than any specialized orientation. I’m typically non-directive and person-centred in session. Mindfulness and self-compassion can be useful, and psycho-education and reframing is common. Somatic activities can be useful for emotional health, and I do role playing activities when appropriate.
My communication is kind, transparent, precise, and direct, though I check in with clients regularly as the therapeutic alliance progresses about any adjustments we could make to our communication. My autistic clients usually let me know when I could be communicating more effectively, either by directly telling me, or if they’re asking me to clarify often, or they’ll say things such as “I don’t know what you mean by that” or “I don’t know what I’m supposed to do with this information.”
As I discuss here, once clients have a secure relationship and have processed emotions that may have been causing avoidance—once acceptance is taken care of—motivation and behavioural change is usually not far behind. Keep in mind there are many potential barriers to building trust, such as fear of rejection or being misunderstood, feeling pressure to use social masking or that therapy becomes “performative,” the client rejecting aspects of themselves, trauma, and so on. Of course, the focus of your work needs to be on goals that clients think matter, not goals that you think matter. At that point, solution-focused work, narrative approaches, CBT, and so on can all be appropriate depending on client preferences.
Language and Terms
As with people in any group, autistic individuals are unique and it’s best to simply ask each client what language they prefer when referring to autism. The DSM5-TR suggests that “autism spectrum disorder” is the currently accepted medical term. The UK’s National Autistic Society has an article on this subject as well. The community’s preferences about specific terms varies and evolves over time.
Using person-centred language is the norm for many medical concerns, but most people in the autistic community prefer identity-first language when they discuss autism. For example, you may hear “I’m autistic” or “many people in autistic communities…” rather than “a client who has ASD” or “a person with autism.” See here, here, and here for a closer look. Interestingly, autistic people tend to use identity-first language related to autism, whereas family members and medical professionals tend to use person-first language. This type of discussion around language evolves over the years, as you may have seen in other contexts.
‘Neurodiversity’ (ND) or ‘neurodivergent’ are broader terms meaning a “variation in the human brain regarding sociability, learning, attention, mood and other mental functions in a non-pathological sense.” For a lot of autistic people, imagining that they have a disorder or a disability is disempowering and frustrating. For others, the idea is helpful and liberating. It will vary from client to client, so explore it with each of them.
‘Aspergers’ was a widely used term historically, but the DSM5 moved away from that term. Some people may say ‘high functioning autism’ to refer to a similar thing, though phrasing things in terms of “functioning” is also generally frowned upon in autistic communities (talking about a person’s level of support needs is perhaps a better choice). Some autistic people still use the term ‘Aspergers’, while others dislike it, find it disrespectful, or are troubled by the history behind the word/name (for good reason).
‘Autism spectrum disorder’ and ‘ASD’, while common terms used in medical or clinical settings, are frowned upon terms by some autistic people, because as I just mentioned, for a lot of autistic people, conceptualizing autism as a disorder or a disability can be disempowering and frustrating.
‘Aspie’ as a short way that some autistic people refer to being autistic, for example “As an aspie, I think…”
‘Autie’ is similar to the term aspie, though I haven’t seen the term ‘autie’ used as often (note: the NAS suggests we usually shouldn’t use this term or aspie, though that some individuals may refer to themselves in this way and this should take precedence when you’re referring to them)
‘Wrong planet syndrome’ is a colloquial term that is sometimes used, gesturing to how ‘alien’ the human species can sometimes seem to a neurodivergent person (in a non-paranoid way). For example, “I don’t understand the people around me; sometimes I feel like I must be from somewhere else”.
Interoception is the ability to perceive the internal state of our bodies, which some autistic people experience differences with. Many autistic people experience both hypersensitivities and hyposensitivities (e.g., disliking bright lights or loud noises, or having a hard noticing certain smells or if your body is too cold, etc.).
Alexithymia describes difficulty understanding one’s own emotions, and it is a subset of interoceptive experience. Approximately 50% of autistic people also have alexithymia, versus only about 5% of the rest of the population.
Knowing these terms is a good way to demonstrate some understanding and care to autistic clients. It’s okay to not know everything and to learn about a group or culture from your clients. However, when significant portions of therapy involve clients teaching therapists about a subject, that’s inappropriate and the wrong person’s needs are being met. Considering the prevalence of neurodivergence and its potential overrepresentation in healthcare settings like emergency rooms (see here or discussed here), healthcare professionals have a responsibility to be well-informed in this domain to provide appropriate and effective care for neurodivergent individuals.
"Should I get Formally Diagnosed?"
This question is discussed in the autistic community frequently. The answer will be different for each person, so if the question of formal diagnosis comes up in therapy, help your clients explore the issue and their feelings and make an informed decision for themselves.
Some reasons why getting formally diagnosed can be positive:
Medical staff are more likely to believe the client actually is autistic, thus hopefully taking your concerns more seriously in relation to accommodations or related health concerns (this is an ugly truth about the stereotypes and ignorance related to autism and their continued prevalence in the medical system. I’m embarrassed and frustrated to have to include this bullet point)
Easier access to academic accommodations—which can make an enormous difference for some autistic people. Workplace accommodations are less formalized than in academic settings, but some employers are understanding; this decision should be made carefully. Many people still err on the side of not disclosing to employers or coworkers out of fear of discrimination
Validation and a sense of confidence in understanding your own experience. In addition to doubt from others and its negative effects, autistic adults can be analytical to a point of anxiousness at times. My clients without a formal diagnosis commonly report that they feel self-doubt about whether or not they are autistic, so a formal diagnosis may help them relax and feel they are “allowed” to make more accommodations for their neurodivergence. Even for people with a formal diagnosis, self-doubt about whether or not they’re autistic can still be fairly common, especially initially
There can be utility in identifying other diagnoses that may be confusing treatment. For example, quite a few autistic people also have some form of ADHD, alexithymia, or a history of trauma. These concerns can ‘mix together’, and in therapy it may help to clarify diagnoses via formal assessments
It may help in research and introspection, for example a person may not have heard of executive functioning differences or sensory overwhelm, but through the assessment process they may learn about these ideas, research more about them, and use that information to better care for themselves. One autistic person shared the following related example with me: “I now take headphones/earplugs whenever I go out—but never used to. Not because I 100% need them or couldn't do without them, but because it's easier and nicer for me and better for my energy and concentration”
Some reasons why getting a formal diagnosis may be unimportant or negative:
Diagnoses can sound or feel like pathology, implying that being autistic indicates that something is wrong with a person rather than them simply being different
Diagnoses try to reduce a massively complex number of variables into one label, and they may be used in a reductionist manner
Getting diagnosed can be expensive (e.g., $1000 to $1500 USD or more) if done privately, depending on how many assessors are involved and how thorough the testing is
Some autistic people simply don’t care. They’ve done screening tests, read the diagnostic criteria, and resonate with comments from autistic peers, which they’ve decided is enough of an answer for themselves. One way to consider this is that a ‘diagnosis’ is like a label someone else puts on you, while identifying is the result of self-exploration.
There is a risk of being mis-diagnosed, particularly if you work with someone who isn’t knowledgeable about autistic adults
It can feel (and be) vulnerable to put yourself into the hands of a stranger (the assessor), and you may be misunderstood
Testing can be stressful, depending on how it’s done, on what kind of flexibility and accommodations are offered
Receiving a diagnosis can be emotionally complex and challenging to process
You may feel or experience discrimination due to having a formal diagnosis (e.g., depending on where you live there might be situations where you’d be legally obligated to disclose)
Deciding to get diagnosed or not is a personal choice. Some cases are quite complex with numerous co-occurring factors and a thorough assessment can help determine how to best help a person. However, many adults functioned reasonably well before they suspected they were autistic, and many people live happy lives without a formal diagnosis.
"Should I disclose that I'm autistic to family? Friends? Employers?"
The realization that you have been autistic without knowing for decades can be disorienting and surreal. Ideally clients could have at least one or two trusted people to discuss the experience with. Therapy is one outlet for this discussion and some clients may not want to disclose to anyone else. This decision is discussed elsewhere, so I’ll be brief. Relevant resources are: Autism UK and Research Autism.
When considering disclosing to family and friends, I suggest clients only disclose to people they trust and feel safe with, and when there’s a reason to disclose. Some possible benefits of disclosure would be feeling more understood and accepted by those close to you, not having to mask as much, having more rationale when asking for or discussing accommodations for sensory issues, and so on. Some clients only feel comfortable disclosing that they have a sensory processing issue, which likely has less stigma yet still allows family and friends to better understand the accommodations being requested. You might think of this as an example of ‘disclosing without disclosing,’ or partially disclosing without using the word autism.
Regardless, I suggest these be brief conversations, simply sharing the facts and maybe a bit of the story of how the client found out they are autistic, then seeing if the other person has any questions and offer to send them a resource or two later if they’d like. When it’s someone the client feels extremely comfortable with, then longer discussions can make more sense.
At work, many autistic people err on the side of not disclosing to employers. A key question to consider here is “what am I actually hoping will be different as a result of disclosing to my employer?” Given the risk of prejudice after disclosure, this has to be a careful decision. Ideally clients will have a trusted family member or friend they can discuss it with as well. I don’t mean to imply that autistic people can’t make their own choices; I simply mean that, when making large choices, having someone to act as a sounding board and getting a second opinion from someone I respect is often helpful for me.
Some countries have better employee protections available than others, but workplaces are quite different than academic settings like universities when it comes to accommodations. Schools (usually) do a good job offering various accommodations to students when required. Some clients are in positions of influence or power at work, and they feel comfortable disclosing and even educating coworkers about autism. This is wonderful and reduces stigma, when it’s a safe choice to make.
Consider having your client role play the disclosure with you several times. Your own therapist training likely used role playing; consider how nervous you were and how poorly you did when first attempting complex therapeutic skills. It can be nerve-racking, and practice helps. I encourage clients to try disclosing to one person, then reflect on if or how they’d like to augment the process (here’s a video explanation).
Identity and Grief after Diagnosis
Some adults feel disoriented about who they are after realizing they are autistic. Suddenly discovering that many salient, quirky things about you are due to this ‘new label’ you don’t know much about can lead to self-doubt. “If I set aside those aspects of who I am, what’s left? Who am I” or “it seems impossible to separate my neurodiversity from most of my experiences, what does this all mean?” And so on. Therapists can simply empathize, support, validate, explore, and consider doing some values clarification or self-compassion work in these moments.
A portion of adults who find out they are autistic experience overwhelming grief. The exact origins of the grief will vary, but in general it’s a feeling of sorrow for themselves, for all the otherwise needless suffering they endured for decades because they didn’t know how to take better care of themselves. They didn’t have an accurate understanding of their unique needs so setting up an environment that suited them well was difficult, as was asking for what they needed, or feeling their “bizarre” needs are actually valid. If you feel like an outcast your entire life but then find out there is a group where you fit in and all your ‘quirks’ are ‘normal’, it can be a lot to process. Additionally, it’s common to experience some complex feelings toward parental figures once a person gets a late diagnosis.
For some clients, each new characteristic of autism they explore that aligns with their personal experience can cause additional grief. In the first few months after diagnosis, clients often try to learn a lot about autism (which may or may not be helpful for them), and ideally therapists can point them toward accurate resources. As time passes, less information is novel so this source of grief alleviates. However, some clients will continue connecting past moments with autistic characteristics as they learn more about it, for months or years following their diagnosis. Even though the client already knows about the events of their life, recognizing yet another connection with autism can be impactful.
In therapy, if your autistic clients express an identity crisis or grief following a diagnosis, give it careful attention. Each person’s experience will be different though. For example, some clients will find out that they are autistic and it will merely be useful information that they can act on.
"Special Interests"
Autistic people may appear to have restricted interests, and they may intensely focus on one or several specific topics. These “special interests” (or SPINs) can be taken to great depth, though a more strengths-based way to conceptualize this is as a subject a person is passionate about. The subject of a passion like this can be anything, for example owl predation patterns, history of barbies and their cultural significance, autism itself, psychology, certain TV shows or books, space, dinosaurs, or criminology! Duration of an interest can be lifelong or simply a few weeks or months. Some autistic adults select a career based in an interest of theirs and thrive. These intense interests may be harder to notice if they are more common in the client’s cultural. It’s also somewhat common for autistic children to have “age-inappropriate” interests (notice the clinical/disparaging language there), such as an interest in opera, the Black Plague, serial killers, and so on, which you might imagine can cause concern (or panic) for parents or teachers; these kinds of negative responses, combined with alexithymia and/or noticeable differences in theory of mind leaves some autistic people worried for decades that there’s something “seriously wrong” with them. It’s not uncommon for me to hear autistic clients disclose that due to experiences like these, they’ve always worried that they might be a “sociopath” or “psychopath” or similar.
Engaging with these passions is usually soothing. Given how confusing and chaotic other aspects of NT life can feel for autistic adults, spending several hours immersed in an area they are familiar with, interested by, and even confident in is appealing. As a therapist, encourage, explore, and validate these interests. Autistic clients likely have been criticized for their interests in the past and may have internalized that, so it can become part of self-acceptance to work through this. If a client is concerned about how their time spent focusing on interests impacts their other responsibilities or life balance, then like any other client goal, consider how to help them with it. However, do not decide for your client that the way they spend their time is unbalanced, and further, do not set goals on their behalf related to “helping” clients find a balance that you think is more appropriate. An exception to this idea that would at least cause me to explore the concept would be if there is somehow a relevant safety concern. It’s quite common for autistic people to “retreat” to a special interest at times as a way to cope; this may be a key coping mechanism for them, which may be healthy or unhealthy, but the point remains that trying to eliminate the interest may be damaging.
Sensory Sensitivities and Stimming
Studies report that over 90% of autistic people experience some form of sensory processing condition. This means a person is overly sensitive to a stimuli that neurotypical people are not as sensitive to. You could think of it like having a bad headache and hearing loud, sharp noises, or someone playing loud music and turning bright lights on while you’re hungover. Many autistic people experience some version of this on a regular basis. Imagine doing this 8 hours a day, 5 days a week. Then add in social obligations on top of that, grocery shopping, etc. It gets overwhelming if unmanaged.
These sensitivities can relate to any sensory experience. Sound is frequently a concern, though light, texture, and touch are common as well (as are many things related to eating). Autistic clients may also have some forms of undersensitivity, known as hyposensitivity—but this is harder to notice and often doesn’t cause as much concern as hypersensitivities do. Note that hyposensitivity to pain can lead to poor medical care due to inadequate attention or treatment being provided.
Do not suggest or attempt exposure therapy to ‘correct’ sensory sensitivities in autistic clients. Don’t dismiss your clients’ concerns about sensory issues they have in your counselling environment.
Helping your clients discover strategies for dealing with their sensory sensitivities can make an enormous difference for autistic adults. Exploring how they might alter a particular environment may be of use, or more likely is that your client will know what change they want or need in a troubling environment, and you could explore how they could achieve it. This will often involve navigating a social situation. There are many products autistic people use that help, and it’s worth having clients search online about their particular sensitivities. Various musician’s earplugs or noise cancelling headphones are good examples.
Interesting example:
Several years ago, I worked with a young adult client who had recently become more sexually active with her partner. She became very distressed during sex in some instances, even shouting at her partner and needing to be alone, despite initially feeling safe and wanting to have sex, as well as enjoying sex with her partner the majority of the time. She was worried the experiences indicated she was triggering repressed memories of sexual abuse or something similar. Early on she also was complaining to me of how noisy children were at her day job and unusual steps she took to avoid the noise. Along with several other indicators, we started to explore sensory sensitivities and found out she did have sensitivities both to noise and touch. My client later realized that on days when sexual encounters went poorly for her, she had been feeling overwhelmed by sensory experiences already but had not been aware of it (poor interoception and/or alexithymia). Once we defined the concern and what was causing it, they were able to make accommodations for it and enjoy their sex life.
People tend to only notice the negative aspects of hypersensitivity, but it’s worth exploring the range of positive sensory experiences available, which can be enhanced by sensitivities. Examples could be soft fabrics, certain colours or combinations, some textures, or certain noises. This knowledge may be useful to enhance clients’ stimming.
Stimming has been written about extensively elsewhere, so you can seek those resources out. Basically, stimming is useful to alleviate anxiety or tension. As is the theme in this article, therapists can explore stimming options with clients and validate their experience when they find and engage with useful ones.
Many autistic people will have experienced criticism and shaming for stimming when younger, leading them to either stop altogether, or hide it and feel embarrassed. Imagine being criticized so much over the years that you internalize it and now can’t use some of your most effective self-soothing tools as an adult. A particularly tragic effect is that due to this kind of shaming, some/many autistic adults will even be hesitant or refuse to stim when they are alone at home.
Social Anxiety and Autism
Autistic Adults often report feeling social anxiety. The cause of this anxiety will sometimes be the same as any neurotypical person’s anxiety and could be treated as such. However, an autism-specific cause of social anxiety can, for some people, come from autism related social differences (i.e., “abnormal social approach” in clinical language). For example, not grasping social cues being given, not communicating interest in a conversational partner’s story, talking at length about a subject no one else present is that interested in, and so on—there are many possibilities for social missteps ranging from mild to severe. This social discomfort is sometimes best explained by feeling ‘unsafe’ socially due to stress of anticipated rejection, masking and resultant exhaustion or cognitive overstimulation, sensory overstimulation, social expectations, and so on. Michael Samsel, LMHC, detailed many examples here.
Oftentimes, an autistic person will not understand why a social encounter turned out poorly. Even when aware of the particular social difficulties they have, your client might not be able to discern if the missteps were occurring during a conversation, or only realizing it after the fact.
Imagine a hypothetical autistic adult named John who is undiagnosed and has not begun to suspect he is autistic. John has awkward, uncomfortable, or unsuccessful social encounters perhaps 40% of the time. In small, repetitive moments such as with a cashier in a store, John knows what is expected and can ‘fit in’ as NT people around him expect. But as the social situations become more complex and unfamiliar with friends, romantic partners, or a tense meeting at work, John can feel unsure of how to act. The book “The Rosie Project” is a light-hearted, imperfect fictional bit of entertainment that is relevant here.
What John is aware of without any doubt, is that important social encounters go poorly for him quite often. And, he knows that simply living in society involves frequent contact with other people, so John knows he’ll have to continue facing these situations that keep going poorly. This could include any encounter, including deeply important and vulnerable ones. It seems like a normal response to feel anxiety about having to keep facing important social tasks where you know you’ll probably make mistakes and be negatively judged—and you don’t know what’s wrong so it’s hard to fix.
This problem leads many autistic adults to feel anxiety about socializing, and often to feel extensive self-blame, that it’s all your fault. This is heightened in new situations or with new people because of the cognitive cost and the uncertainty—not to mention the ‘certainty’ that John worries he will likely make mistakes and hurt people or look foolish. So autistic adults can feel overwhelmed in social situations and experience social anxiety. Sensory overload can also cause autistic people to feel overwhelmed and agitated, which can make it easier to feel anxiety, perhaps causing a person to become more rigid and stressed. Asking for accommodations, as in, having to communicate about needs that the other person may find uncommon can add an additional level of discomfort to some social situations.
Anxiety in autistic people is a complex subject. See the article Unmasking Anxiety in Autism (2017) for a more thorough look. “Anxiety can assume unusual forms in people with autism — turning uncertainty, or even a striped couch, into a constant worry.”
Eye Contact
A 2021 study with a sample of 70 participants indicated that difficulties with eye-gazing patterns and eye contact might be attributed to alexithymia rather than autism. Alexithymia, characterized by challenges in understanding and articulating one's emotions, affects approximately 50% of autistic individuals compared to roughly 5% of the general population. This factor may contribute to some of the diversity observed in both research and the experiences of autistic people. Therapists can validate and normalize the discomfort associated with maintaining regular and prolonged eye contact for clients who find it challenging. Eye contact can be considered an intensely demanding social experience, as it involves giving, receiving, and interpreting micro-feedback. When neurotypical expectations, such as specific reactions, are anticipated, it can be stressful for autistic individuals to decipher and deliver the expected response or to navigate the situation when the anticipated response is not provided.
There are some well-known ‘tricks’ in the autistic community to make social encounters more manageable, such as looking at the bridge of a person’s nose rather than their eyes, or taking lots of written notes to have something productive-seeming to be looking at, or commenting on something the person is wearing or something in the surrounding environment, and so on. So the person with alexithymia feels more comfortable, and the conversational partner who’s expecting at least some eye contact perceives that eye contact is occurring. These kinds of behaviours gives the appearance of eye contact (or an excuse to not be using it that NT people might feel comfortable with) but don’t have the same felt intensity of actual eye contact. As always, be careful when sharing ideas like this not to be encouraging masking. While it may not be ideologically perfect according to some, I’ll simply report that I’ve seen many autistic adults share tips like this that make their life in an NT world a bit easier. Also, note the following descriptions for how eye contact feels that I regularly hear from autistic people: uncomfortable, overwhelming, overstimulating, overly intimate, makes it much more difficult to focus cognitively, and so on.
Paul Micallef, who hosts the well-known Youtube channel Autism from the Inside, shared this video in late 2021 discussing when masking might be useful. He does a great job explaining why masking is unhealthy and unpleasant to do, and the only redeeming point he makes about masking is that sometimes it’s nice to simply ‘fit in’ enough in a situation to avoid drawing attention to yourself.
Burnout and Autism2>
Autistic people likely experience burnout at a higher rate than people who are neurotypical. Periodic burnout is almost inevitable when a client doesn’t know they are autistic and they aren’t making accommodations to change their environment to better fit their needs. All the energy spent masking, not getting enough solitude to recover, the anxiety, the constant sensory bombardment. It makes a person feel exhausted and awful, if there aren’t enough mitigating factors.
Since autistic adults have always experienced the world in this way, this stress or burnout can feel ‘normal’. Having these clients fill out a few burnout screening tests periodically may be appropriate. This can improve clients’ awareness of their level of burnout, which otherwise may feel normal—a discomfort they’re so accustomed to that it’s become part of the background noise of living. At times, pronounced cycles of engagement and disengagement (shutdown/withdrawal) with work/life balance may appear to be an optimal working style, thereby complicating the identification of detrimental burnout as opposed to merely engaging in intense work followed by a period of rest.
Once a person realizes they are autistic, the issue of burnout can improve dramatically. Searching online for “autistic burnout” will yield many personal accounts of the experience as well as suggestions. Once an autistic person better understands their own needs, they can more specifically meet them. Beyond that, fascinating research from Raymaker (2019) found that,
“autistic traits were not positively correlated with psychological distress, but efforts to camouflage these traits were. This indicates that it is not the experience of being autistic that creates distress, but the pressure to conform, keep pace with our neurotypical peers, and hide our true selves that causes psychological distress”
This idea is central to my suggestion to focus on self-acceptance. Once an autistic person feels more self-acceptance and compassion, they typically feel more comfortable engaging with useful accommodations and coping skills. There are an endless number of coping skills and ideas available, when clients feel ready for them.
Trauma and Autism
Research into autism and trauma is still minimal, though starting in perhaps 2017 a search for PTSD and autism does yield substantial academic sources. Research has yet to discern correlation from causation here: “does autism predispose someone to post-traumatic stress, or are people with autism more vulnerable to experiencing traumatic events? Or both?” These researchers do speculate that “autistic children are more reactive to stressful events and, because they lack the coping skills that help them calm down, perhaps predisposed to PTSD”.
PTSD can present in unexpected ways in autistic adults and it “can exacerbate autistic traits, such as regression of skills or communication, as well as stereotyped behaviors and speech,” according to Connor Kerns, a Researcher at the University of British Columbia who focuses on autism.
PTSD in autistic people may tend toward characteristics of hyperarousal—being “more easily startled, more likely to have insomnia, predisposed to anger and anxiety, or have greater difficulty concentrating than is seen in other forms of PTSD.”
Kerns’ group plans to create a trauma assessment specifically for autistic people—though as of early 2022 this assessment tool is still in the prototype stage (via personal communication). Kerns discussed that until recently, the research consensus was that autistic people had a prevalence of PTSD similar to the rest of the population: 3%, and that this would “be one of the only psychiatric conditions that’s no more common in people with autism than in their typical peers,” which suggests prevalence of trauma in increased in ND populations.
Anecdotally, many people in the autistic community discuss feeling like they have experienced trauma, that the characteristics of PTSD are overly familiar to them. However, to medical professionals, if the presentation of trauma is different enough that traditional screening tests fail to detect it effectively, there could be many more traumatized autistic people than merely 3%. My guess is that this is the case, and I look forward to research catching up on this important topic. Further complicating the matter is that alexithymia could make recognizing and describing one’s trauma more difficult. Some autistic adults get asked by NT people and healthcare workers if they’ve experienced abuse because the autistic person is very quiet, doesn’t make eye contact often, is easily startled by noise, and so on. Numerous autistic adults who have had this experience told me that they have not experienced trauma and believe these traits to be related to their autistic characteristics, not trauma.
It often seems to be the case (from my clinical experience, engaging with the larger autistic community, and some research), that what is typically understood to ‘cause’ trauma may be too narrowly defined, especially for autistic people. It may be that any experiences that overwhelm a person’s ability to cope have the potential to cause lingering difficult effects, particularly if the experiences are intense or happen repeatedly. Some autistic people seem, for example, to be very impacted by difficult social experiences. In a personal communication, Paul M said to me “I personally believe that a broader, more inclusive view of trauma, and emotional regulation in general would be immensely helpful. I think there's enough evidence to suggest that any 'non-expressed' emotion can cause significant harm (especially in the long term)”; see one of his videos on autism and trauma.
In a discussion of autism and trauma, one autistic person articulated their experience as:
“These traumas are real and have affected me all along. The source of these traumas is not that I am ‘too sensitive’ or anything else: it is that I am neurodivergent [and am] forced to live life pretending to be otherwise. It is still trauma—any stims are responses to real anxiety, I still grew up with people thinking I felt things differently than I experience[d] or being told that I was wrong. I still grew up in a world that is too loud and too bright, and when forced into those overbearing situations with no support, understanding, or escape, I was traumatized.” I think it’s ideal to get a sense of the research while also hearing directly from autistic people.
Trauma in autistic children can be caused by all kinds of situations. Kerns gave the example of a 12 year old who “refused to go to school and was hospitalized for threatening self-harm; the root of his trauma turned out to be ear-piercing fire drill[s].” Other clinicians suspect that increased prevalence of trauma in autistic children is due to them being at increased risk of bullying, ostracizing, and other forms of abuse. Golan, one of the researchers, explained that in their sample, these autistic children were very sensitive to the aforementioned social events, that these events “predict PTSD more strongly than violent ones, such as war, terror or abuse, which are not uncommon in Israel. Among typical students, though, the researchers see the opposite tendency.”
An evolutionary psychologist might see the above as an example of how, when humans lived tribally or nomadically, making serious social missteps that lead to being ostracized often meant death. To survive, having good enough social skills to maintain harmony in the group was important—but what about a person who struggles to read some social cues and makes mistakes without meaning to or understanding why? This can lead to shame and internalized ableism. Further, autistic people will likely have had their concerns invalidated, being told that they are “making a fuss over nothing” or that “no one else is complaining or having a hard time with this situation—why are you always so dramatic?” And so on.
Thoughts on Treatment
An autistic adult described the complexities of autistic characteristics and trauma and the benefits of treatment in an illuminating way:
“Getting treatment for my trauma was very eye opening because I started being able to deal with the trauma responses much better by developing healthy coping strategies and found that some of my sensory issues became more manageable too. It was kind of like when two Christmas light strings get hopelessly tangled together, so that when you look at them you can't even tell the two strands apart. You have to sit down and start plucking at strands, detangling little by little until you have two straight strands again. So… how do you differentiate between trauma and autism? Basically... You can't. At least not without healing from trauma and seeing what's a scar and what was there all along.”
As for treating trauma in autistic people, studies found that trauma-focused CBT is one of the most effective approaches, even including parents or guardians in the work when clients are minors. This treatment also involves psychoeducation for all parties on what trauma is, how to handle challenging moments, how to communicate in healthy and effective ways, and techniques for self-soothing. Therapists in this study helped clients discuss the experience so they could feel more in “control of the narrative, reframe it and make it less threatening.” This process can take longer in autistic minors than in NT minors.
I’m not a zealot for CBT, though having a well organized and systemic approach does seem important in this case. I believe that emotional literacy and intentional emotional health is a very important (and typically neglected/stigmatized) aspect of human health, so focusing solely on cognitive therapies seems ill-advised. Further, CBT is often effective at helping the kinds of things it is well-suited for; however, make sure that what your autistic clients need is appropriate for CBT interventions prior to applying it. Anecdotally, it’s common to hear from many autistic people that they dislike CBT, and here is a great explanation of why.
Additionally, gradual exposure therapy can apparently be effective for treating some kinds of trauma in autistic adults. However, be cautious in applying this and only proceed if your client agrees. Even then, start very gently, check in frequently, and reassess after each step. My guess is that many existing trauma-informed approaches to therapy could be appropriate for autistic adults with trauma, modified to suit each particular client.
Dr. Tasha Oswald (2020) discussed how social situations and associated masking, anxiety, and missteps may contribute to trauma. Further, this study explored how interpersonal traumas and adverse outcomes seem to be more likely to occur in some autistic populations.
In reviewing relevant research for 2018-2022, the conclusion seems to be that some mental health concerns can present differently in autistic people (e.g., trauma responses). The other common conclusion is that much more research needs to be done in this area, particularly for autistic adults. Therapists must carefully screen autistic clients for histories of trauma. Typical screening tests and questions may not suffice, and keep an open mind about what type of events may cause trauma.
Emotional Health and Meltdowns
Tony Attwood is a psychologist well known for specializing in working with autistic adults. He explained that many autistic people have difficulty with moderate emotional experience. While an NT person may experience the intensity of an emotion on a full scale of 1 through 10, autistic people may feel they only experience either the low end of emotional intensity (1, 2, or 3 out of 10), or the high end (8, 9, or 10 out of 10). Many autistic people have powerful and intense emotional experiences, seeming to jump from feeling quite normal and calm to quite distressed without going through an intermediary phase. Going through this all day is exhausting. Further, many autistic people are “overly sensitive to another person’s negative mood”, being greatly impacted by being in the presence of people feeling this way. A metaphor Tony uses is to say if one person has a cold (i.e., a mild emotion), the autistic person nearby can get infected by this, but they don’t merely get a cold—they get the flu (i.e., a strong emotional response). Autistic people can also be “hyper-sensitive to disappointment, anxiety or agitation.” Tony’s presentations can be useful resources.
Emotional wellbeing is important for everyone. Approximately 50% of autistic people have alexithymia, so therapists should pay careful attention to the emotional descriptions from autistic clients. Often people with alexithymia can improve their self-awareness skills and their ability to identify what their feeling with some practice and tools. A feelings wheel is a critical tool to expand emotional vocabulary, like an emotional dictionary to reference when a person feels “off” in some way. See my articles on emotional regulation and emotional processing for a deeper look at emotional health in therapy.
Interoception is the ability to perceive the internal state of our bodies, which could be seen as related to emotional awareness as well. However, more recent studies are suggesting difficulties with interoception are linked to alexithymia, not autism. Regardless, you can search online for activities to improve interoception, which often centre around mindfulness. Interestingly, many autistic people are highly empathetic and sensitive—particularly in relationships—and working on emotional boundaries is often useful.
Meltdowns are an intense response to an overwhelming situation. It happens when someone becomes completely overwhelmed by their current situation and temporarily loses control of their behaviour. This loss of control can be expressed verbally (e.g., shouting, screaming, crying), physically (e.g., kicking, lashing out, biting) or in both ways.
Some autistic people experience meltdowns. Meltdowns tend to occur because a person hasn’t noticed how overwhelmed they’re becoming and/or has been unable to resolve what’s making them feel that way. Many autistic people, unfortunately, live close to the line of being burned out due to masking, sensory issues, alexithymia, and so on. It may not take much external pressure to cause them to feel overwhelmed. Meltdowns can also involve shutting down, withdrawing, leaving the situation, or refusing to speak. An individual's "emotional capacity" may be at 99%, appearing functional; however, even a minor issue can elevate this to 100%, resulting in a "meltdown" or shutdown as a stress response. Some autistic individuals may find that, due to their communication style and (potentially different) non-verbal cues, when attempting to convey their approaching emotional limit, they may appear untroubled, causing others to not take them seriously. This can make it complicated to effectively communicate about boundaries and the gravity of requests.
Solitude and Routine
Requiring a significant amount of time alone to recharge is common for autistic adults. The potential challenges discussed above describe why an autistic adult could want extra solitude: to get away from confusing social situations, to let go of masking for the day, to reduce exhausting or painful sensory stimuli, and so on. When a person doesn’t know they are autistic, they will almost certainly have incomplete information about what specific needs they have, and their need for solitude may be heightened. Once a person knows they are autistic they have the information required to structure their life to better suit their particular needs—in some cases (only some) this can reduce the need for solitude, as they can now more effectively meet their needs thus feel overwhelmed less often. At this juncture, some people will realize how thoroughly they’ve been masking and need even more time alone—that’s okay too.
Many autistic people will have experienced criticism about their alone time from friends, family, coworkers, or romantic partners. Therapists can validate this need and explore its origins.
The outside world can feel chaotic to an autistic person, and all the bottom-up processing and sensory processing issues can, understandably, leave a person wanting to reduce this chaos. A way that some autistic adults try to accomplish this is by establishing clear and predictable routines. The familiarity of each routine is calming and may also unconsciously accommodate for sensory issues they have. Routines also allow for fewer new things to overcome and process, which leaves more cognitive resources available for other activities each day that are taxing, such as work or school.
Ann Memmott describes autistic routines: “Autistic people learn differently, and will focus on specialising on one subject first, before generalising that to others. Many will use objects as part of a needed flow, ritual or relaxation technique, in the same way as some cultures use ceremonies to relax and de-stress. This may look like lining things up, or using the same movement with a toy over and over. Other people may not detect the slight differences we're tested [sic], or understand why.” Keep in mind that routines also reduce the energy needing to be spent on executive functioning, as figuring out new ways of doing certain tasks can be a very large energy investment for autistic people.
In therapy, be careful suggesting that clients consider adjusting their routines unless the routine significantly impacts their functioning, is a safety concern, or the client wants help changing it. If a client enjoys driving home on a specific route that takes 15 minutes longer than the most optimal route, who are we to judge? The same goes for their plan to always eat the same meals on each weekday, or things similar to this.
In ‘A Memoir of Marriage, Aspergers Syndrome’ by David Finch, David described some of his old routines. He spent hours each evening flicking light switches in each room and staring out the window at his neighbours’ house lights, observing their timed shutoffs and so on. He did this while his spouse parented their two young children and did household tasks. David, an engineer and sales consultant, recognized that this didn’t seem fair, that his spouse did a huge amount of work being a parent every evening (after she worked each day) while he simply wandered the house for hours on his routines. It may seem like bizarre activity, yet this routine was soothing and took him a long time to adjust.
Lastly, social stories are a common tool used when working with autistic children. “A social story is a narrative made to illustrate certain situations and problems and how people deal with them. They help autistic children understand social norms and learn how to communicate with others appropriately”. Common kinds of social questions from autistic people are:
Why did she do that?
How did they know it was ok to do that here?
How does everyone just know what to do in this bus station?
As always, therapists have to be careful to not promote masking and suppression of authentic identity, but at times there likely are advantages for adults to know what’s expected in various professional or social settings. Some adults can augment the concept of social stories to benefit them, in a form of self-coaching. Ideally, social stories will include why the person is doing what they are, rather than simply what they are doing and what’s expected; someone gave me the example that “it took me decades to figure out that people danced because it made them feel good.” An example from Kristin Neff related to emotional turmoil is:
This is a moment of suffering
Suffering is a part of being human
May I be kind to myself in this moment
May I give myself the compassion that I need
Autistic Women and "Non-stereotypical Presentations"
The majority of existing autism research and prevailing stereotypes are largely based on historical observations of autistic males. However, it's crucial to recognize that autism is not exclusive to one gender. Many women, as well as other individuals who do not identify as male, are also autistic. Their manifestations of autism, however, can differ, possibly due to societal gender norms and the conventional ways in which girls are often socialized in Western societies. See the 2021 videos here by Samdy Sam and Purple Ella for additional perspectives on this subject. Both of these Youtube creators identify as autistic and are well known in the community.
Historically, women's health issues have often been overlooked, misdiagnosed, or trivialized, as evidenced by multiple sources (see here, here, or here for further reading). Therefore, it may be more accurate and helpful to consider an alternate conceptualization of autism, rather than simply labelling it as a “female presentation of autism.” This alternate view recognizes a presentation of autism that is characterized more by internalization, extensive use of social masking, interests that may align more closely with those of their peers of a similar age and gender, and a socialization process that emphasizes agreeableness and refined social skills to avoid punishment. Moreover, individuals with this presentation of autism are likely to have superior language skills and a higher IQ. By understanding and acknowledging these different presentations of autism, we can ensure a more comprehensive and inclusive approach to assessment and therapy.
Non-stereotypical variations of autistic traits have been defined and are useful to many people; see Samantha Craft’s work for one explanation. Samantha later updated her list and acknowledged that thousands of people across the entire gender spectrum have identified with this list. Therapists could think of this as a common but non-stereotypical presentation of autistic characteristics, a non-medicalized perspective. This is the kind of presentation that is more likely to be dismissed by healthcare professionals. More broadly, if a behaviour can be easily dismissed as something else that is generally accepted in a given culture (for example, saying a child is “just lazy”), it's more likely to be dismissed.
Between how differently autistic characteristics can present (perhaps especially in women) and how often the medical system dismisses their concerns, neurodivergent people are under-diagnosed and misdiagnosed frequently. A lifetime of being treated this way by doctors and therapists leaves many marginalized people less likely to seek help, feeling timid, anxious, or even defensive when they do speak with healthcare professionals. The term ‘medical trauma’ addresses this and is something neurodivergent adults may discuss in therapy.
Autistic people with non-stereotypical presentations who suspect they are autistic have that belief dismissed by their family doctors frequently. Even psychiatrists and therapists tend to be dismissive toward autistic women. Though the stigma toward autism is reducing, it’s still difficult or uncomfortable for some people to admit the possibility that they are autistic, even to a healthcare professional. Further, it’s tragically common for a doctor to respond confidently despite their ignorance. For example, see this anecdote from a woman in her late 20s who suspected she was autistic so decided to work with a psychiatrist:
An organisation helped me and donated to afford a meeting with a psychiatrist, they even helped me choose the doctor. I was so scared and excited, I decided to write everything down to help myself through the process. I spoke about my childhood, my sensory issues, my troubles with socialization, synesthesia, special interests, meltdowns etc. He stopped me and said that I can't be autistic because I have empathy and a boyfriend that I love and want him to love me back. The psychiatrist added then that autistic people don't care about love and can't be empathetic. I was shocked and I was asking questions trying to understand his point, I was exhausted after that meeting. I don't think that he is right and he probably needs to learn more information about everything, but I am still confused. I read a lot of information before this meeting (5-6 months were spend to learn more about autism and myself).
This is painful to read and I wish I could believe it was rare or that it happened 50 years ago. But in happened in 2021. Here’s another example from early 2022. I see this in the autistic community all too regularly. Many people experience this type of dismissal from healthcare professionals who are supposedly experts in mental health—psychologists, psychiatrists, MSWs, LCSWs, etc. Add in white coat syndrome, and this kind of rejection surely leads many people to stop seeking help. “The biggest threat to the human intellect isn’t being ignorant, but being under the illusion of knowledge.”
When autistic women were asked about therapy and what they’d wish therapists understood, they explained things such as:
“Try to listen to someone suggesting autism to you with an open mind. We have trouble communicating, so while we may have done proper extensive research, our presentation of it can still come off as thin, stuttery, lacking, unconvincing, etc…I had my suggestion of autism dismissed four separate times yet I am now officially diagnosed”
“My struggles may be invisible, but they are valid. Just because I appear neurotypical does not mean I am. If I tell you about a struggle I have please do not invalidate me by saying ‘everyone deals with that’ or ‘but you can’t be struggling that badly; you have a college degree.’ Please, just validate my experiences”
“I want you to know that I have a high school diploma. A vocational degree. I have a high IQ. I raised a son into adulthood. I can hold conversations. I feel empathy. But that doesn’t mean I don’t struggle. I’m still socially awkward….I present well. I mask well. But that doesn’t mean I struggle less. Don’t write us off just because we can be successful”
As with any misunderstood or marginalized group, it’s best to hear directly from voices within that community. The above quotes are more authentic and moving than anything I could have written. I hear these concerns over and over from neurodivergent women. It’s tragic and we need to do better.
A 2014 study explored differences between autistic males and females. The sample was children aged 4 to 18, with 304 females and 2114 males. Interestingly, they found that for participants with IQs above 70, the most pronounced difference between autistic boys and girls was that girls were less likely to have restricted interests. Girls’ interests were still restricted somewhat, but often their interests were more ‘socially appropriate’. For example, while an autistic boy may talk at length about train timetables, an autistic girl may go on about their favourite singers or a makeup collection. Autistic girls may also be less likely to be interested in repetitive behaviour than boys. Another study found that autistic girls consistently had superior social skills when compared to autistic boys, though the autistic girls did score lower when compared to neurotypical girls.
Effort is being put into creating more accurate screening tests for detecting autistic characteristics in women. A 2020 study of the utility of a modified version of the Girls Questionnaire for Autism Spectrum Condition (GQ-ASC) yielded promising results. Broadly speaking, this screener looks at 5 categories:
Imagination and play
Social masking of autistic traits
Sensory sensitivities
Socializing (barriers to understanding and participating)
Interests (age-advanced and non-stereotypically feminine interests).
This screening test correctly identified 80% of cases (with a cutoff score of 57), which is excellent. This is what the screening test looks like:
Lastly, I haven’t seen much research outside of cisgender folks related to autism. Recent research is beginning to consider this question, such as this study from 2020, that found “substantial overlap between autism and transgender identity.” I imagine quite a bit more research in this and related areas will be done in the coming years. It seems that the less privilege a person has in a society, the more likely their experience or suspicion of being autistic is to be marginalized and dismissed in the healthcare system.
To sum up, keep in mind that many autistic adults are so effective at masking that few people (if anyone) would suspect they are autistic. If a client is suggesting to you that they may be autistic, earnestly explore the possibility with them.
Positives of Neurodivergence
As part of the self-acceptance work some clients may want to do, focusing on positives of their particular neurodivergence can help. This isn’t meant as ‘toxic positivity’ or to be invalidating; it can feel like a struggle to survive in a neurotypical world at times. However, it is important and healthy to perceive the world as clearly and honestly as possible, and part of that can be acknowledging the benefits of neurodiversity. Here is a lovely example from ‘Snous’:
Resources
Books
Divergent Mind: Thriving in a World That Wasn't Designed for You - Jenara Nerenberg
Nerdy, Shy, and Socially Inappropriate - Cynthia Kim, a very relatable book for many people
Knowing Why: Adult-Diagnosed Autistic People on Life and Autism - Elizabeth Bartmess
The Journal of Best Practices: A Memoir of Marriage, Asperger Syndrome, and One Man's Quest to Be a Better Husband - David Finch
Been There. Done That. Try This!: An Aspie's Guide to Life on Earth - Tony Attwood (ed)
The Electricity of Every Living Thing: A Woman's Walk in the Wild to Find Her Way Home - Katherine May
Spectrum Women: Walking to the Beat of Autism - Barb Cook (ed)
Safety Skills for Asperger Women - Liane Willey
Uniquely Human: A Different Way of Seeing Autism - Barry Prizant, a beautiful book for parents of autistic children
Pretending to be Normal - Liane Holliday Willey
Online
Erin Bulluss, Ph.D and Abby Sesterka are great authors who write in an empowering way about autism. “Erin and Abby are both late-diagnosed Autistic women who write collaboratively about issues relevant to autism, drawing from both scholarly literature and their lived experiences. Abby and Erin aim to create authentic narratives to promote acceptance, understanding, and wellbeing for Autistic individuals.”
succeedsocially is a resource that gets very specific about advice for many social situations and social questions, though it may inadvertently encourage masking. I don’t think it’s unethical to try and answer these kinds of social skills questions (or to help clients find their own answers) if we’re also talking about healthy neurodiversity, self-acceptance, the health impacts of masking, self-care, etc
Therapist Neurodiversity Collective is a group who provides free access to information to help therapists work effectively with neurodiverse clients
Conclusion
Autistic people “often struggle with self-validation and defining our own success because we have been subconsciously (and often consciously, especially among the late-diagnosed) measuring ourselves by the standards of an allistic-dominated society. Many humans struggle with this, as I’m sure you’ve observed in your practice, but for autistics, it is often one of our core wounds.”
Autistic adults seek therapy far more often than most therapists are aware, whether these clients know they are autistic or not. There will always be more groups and therapeutic concerns to learn about, but I think the roughly 75 million autistic people globally deserve better treatment than they’ve been getting from most healthcare professionals.
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