Why Doesn’t Standard Talking Therapy Work for Autistic People?
We know that 70% of autistic people will be diagnosed with at least one mental health problem at some point in their life. This means that autistic, neurodiverse people, and people with a diagnosis of ASD, ASC or Asperger’s syndrome are more likely to struggle with their mental health than the general population.
Despite this high prevalence, most talking therapies have been designed to suit a neurotypical thinking style.
While many autistic people have benefited from psychological therapy designed for neurotypical people, research shows that autistic people respond better to therapy when it has been adapted to suit their thinking styles.
The Nice Guidelines (2012) recommend that autistic people who need therapy for a mental health problem should receive therapy that has been adapted to take account of their autism, ASD, ASC or Asperger’s diagnosis.
So why doesn’t standard talking therapy work for autistic people? What are the problems with unadapted therapy? And how should therapy be adapted?
Here are eight reasons why standard talking therapy doesn’t work for autistic people:
1) Most Therapies Rely on People Being Able to Recognise and Report Their Mood.
Common interventions require the client to self- report their mood and monitor how it changes depending on their thoughts and behaviour. Simply put, the therapist may assume you can easily tell how you feel and tell them about it.
Studies have shown that approximately 50% of autistic adults have alexithymia, this means that a significant proportion of autistic people struggle to identify, name and communicate their mood.
This means that the therapist may need to spend some extra time helping you to identify your feelings. You may also need to work together to develop a way of communicating these feelings.
2) The Therapeutic Goals are Not Appropriate for an Autistic Person.
If the therapist does not have experience or understanding of working with autistic people they might mislabel normal autistic behaviour as disordered neurotypical behaviour. For example, avoiding busy social situations might be interpreted as social anxiety when actually the you may just find busy social situations too noisy and unpredictable. Repetitive stimulation seeking behaviour (stimming) might be misinterpreted as compulsive behaviour associated with OCD.
It is important to consider any unusual behaviour in the context of autism. The therapist needs to work with you to determine whether your behaviour is meeting a sensory need, helping you to function or whether it is the result of a mental health problem.
3) Autistic Burnout is Not Recognised.
Autistic burnout refers to the way autistic people can become exhausted as the result of every day stressors. These stressors may seem inconsequential to a therapist if they are not familiar with the sources of stress for autistic people. Unfortunately, they may also interpret the symptoms of autistic burnout as depression. Many common approaches to treating depression in neurotypical people involve gradually increasing the persons activity levels. This is likely to exacerbate autistic burnout.
4) The Therapy Requires the Client to Take an Alternative Perspective.
Some therapeutic techniques involve asking the client to think about the problem as if they were someone else, a friend or family member. While this can be very useful for non-autistic clients, it is something that can be particularly difficult for autistic people to do.
5) The Therapy Relies on Cognitive Challenging.
Therapies like Cognitive Behaviour Therapy (CBT) use techniques for challenging our thoughts and beliefs. These techniques assume the client has a high degree of flexibility in the way they think and that they can be taught to use alternative strategies for interpreting situations and information.
For many autistic people, changing methods of selecting, processing and interpreting information is very difficult.
While some autistic people may manage to engage in cognitive challenging exercises, research has shown that it is difficult for many autistic people.
Therapists tend to get better results for their clients by working on their behaviour rather than their thinking style. This means that for autistic people it is often more effective to ‘do’ something different rather than try to ‘think’ something different.
6) The Therapist has a Neurotypical Communication Style.
Neurotypical communication can include interrupting people to check something out or challenge the person’s interpretation of events. For Autistic people this interruption can cause them to lose their focus and forget what they were going to say.
Neurotypical people often use turns of phrase or questions that are confusing for Autistic people. For example ‘where are you at with that?’ or ‘what would look different if x happened?’. These sorts of questions are likely to be too vague for the Autistic person to know what is required of them and can cause a breakdown in communication.
The therapist may include too many concepts within a sentence or question which may mean the client does not get long enough to process the question before being expected to answer. Autistic people often get ‘stuck’ on processing one part of the sentence and unable to move on to processing the rest of the questions because of this.
Therapists can adapt their communication style to suit the needs of the autistic person by checking which of these issues might apply to the client and adapting their communication style.
7) The Social Demands of the Therapy Session are too High.
Sometimes Autistic clients feel they need to ‘mask’ or perform socially within their therapy sessions. They might have to make an effort to make small talk, to model neurotypical behaviour with regard to eye contact, body language and personal space. This can make the session feel too demanding before they have even begun to think about their problems.
The therapist can adapt the therapy by asking the client what they would find most comfortable, letting them know that eye contact is optional and that they do not need to make small talk.
8) There are a Limited Number of Sessions.
Autistic people often need a few extra sessions for common mental health problems such as depression and anxiety. This is to allow for extra processing time and for some adaptations such as emotion identification.
When the Autistic person is having long term difficulties with burnout or meltdowns they may need more sessions to understand their problems and address maintaining factors in their lives.
So how do I find a therapist who can adapt therapy for autistic people?
Despite this list of problems with un-adapted therapy, many Autistic people have benefited from therapies designed for neurotypical people. One of the most important components of therapy is the therapeutic relationship, feeling heard and understood.
Sometimes this is enough in and of itself and people’s symptoms of anxiety or depression start to recover without specialist input. Some of the Cognitive Behavioural Therapies (CBT), such as CBT for depression have a very straightforward, structured, and practical component to them, which means there is a good chance they will be accessible to at least some of the autistic community.
In the UK Clinical Psychologists are all trained to understand some of the adaptations a person with Autism might require and some have had further training to make them more specialised. Many of the UK’s CBT therapy services (such as those available through your GP) will have some staff with additional training in working with Autistic people.
If you are worried about whether your therapist will be able to adapt your therapy to suit your needs it is worth discussing this with them directly, or asking a friend or relative to do so for you. You could email them this article, highlighting the paragraphs you think might apply to you or you could print it out and take it to your session to aid your discussion.
I specialise in providing therapy for autistic people, particularly those experiencing autistic burnout. I have written a blog series and an online course to help people recover from autistic burnout. For news of my latest posts and resources please follow me on Facebook or Twitter
Proportion of Autistic Adults with Alexithymia: