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Why Therapy May Not Always Help Autistic People: Part 1
By Miriam Edelman, MPA, MSW

Note: This piece explains why therapy can be difficult for some autistic people. This piece does not discuss problems that affect people in general (ie, many therapists do not accept insurance, and therapy is expensive); however, those financial problems may be worse for autistic people, as many autistic people are unemployed. This piece also does not discuss Applied Behavior Analysis therapy, which is controversial. Despite these challenges, therapy in general can benefit autistic people.

April is Autism Advocacy Month and the first Autistic Advocacy Month. Autistic people have higher rates of psychiatric conditions than members of the general population. Autistic people may have anxiety and depression and nine times the likelihood of suicidal ideation. However, for a variety of reasons, autistic individuals may not always receive effective mental health treatment. Many clinicians have not received adequate training about disabilities in general and autism in particular. Social workers should be aware of these challenges so they can be prepared to work with autistic people and avoid these problems.

Autism
The world’s general lack of acceptance of autistic people is likely a contributing factor to autistic people’s mental health issues and suicidal thoughts and behavior. An article, entitled “Cross-Cultural Variation in Experiences of Acceptance, Camouflaging and Mental Health Difficulties in Autism: A Registered Report,” describes a study of 306 autistic people from eight nations, including 40 people in the United States and similar numbers in the other countries. Just 32.5% of autistic people in the United States felt that society generally accepts them as autistic people, 45% felt accepted sometimes by society, and 22.5% felt accepted. As low as the general acceptance rate in the United States is, it is much higher than the 14.3% in Japan, 15% in Australia, and 16.7% in the United Kingdom.

As Psychology Today reports, autistic people live “in a world not designed for them.” Throughout life, autistic people may be bullied, marginalized, excluded, discriminated against, and forced to conform. Up to 85% of autistic people are unemployed. Even when they are employed, they may work part-time and/or be overqualified, overeducated, and underpaid. Prolonged unemployment may cause mental health problems. Some may seek revenge to remedy injustices they have experienced. They may also want revenge as a result of violations of rules, as many autistic people “have a strong sense of fairness and adhere strictly to rules and routines.”

Therapy Sometimes Does Not Work for Autistic People
There are many reasons why therapy may not work for autistic people.

Lack of Appropriate Training
Many social workers and other mental health professionals are not adequately trained about disabilities. There is little disability content in the social work curriculum. Although clinicians may learn about disabilities on their own, they are often not prepared to care, and consequently do not provide the best treatment, for clients with disabilities. The lack of training is central to problems that autistic clients may have with therapy.

According to “A Blind Spot in Mental Healthcare? Psychotherapists Lack Education and Expertise for the Support of Adults on the Autism Spectrum,” by Lipinski et al, “Autistic adults have difficulties accessing mental health services. The most-reported barriers to accessing treatment are therapists’ lack of knowledge and expertise surrounding autism, as well as unwillingness to treat autistic individuals.” Their study involving 498 adult-patient therapists showed that many therapists do not know basics about autism. Examples include 72.9% incorrectly thinking that “autism in an emotional disorder” and 43.2% wrongly thinking that “autism can be caused by vaccination.” According to the authors: “Psychotherapists rated their education about autism in formal training, and competency in the diagnosis and treatment of patients with autism, lowest compared to patients with all other diagnoses surveyed in the study, including those with comparable prevalence rates. Many therapists had misconceptions and outdated beliefs about autism.”

The article reports that the most common reason why therapists do not treat or are reluctant to treat autistic patients is “I don’t have enough knowledge about autism,” which was 70% of answers.

Lack of Understanding of Autism
The lack of training and thus understanding about autism leads to unnecessary problems. “A Mixed Methods Study of Autistic Adults’ Mental Health Therapy Experiences” reports the following examples:

• P140: Therapy has been ineffective because “my therapist frequently doesn’t understand my lens through which I view the world.”

• P27: Her therapist “viewed [autism] in a stereotypical way and so didn’t really validate me and kept trying to respond to me through a neurotypical lens.”

Without understanding autism, therapists may have difficulties understanding autistic people’s problems and thus may not provide beneficial treatment. As autistic people tend to be unemployed, a highly educated autistic individual very well may not have a job and thus may have related mental health problems. The typical advice for getting a job may not prove to be successful for autistic people.

Ineffectiveness of Traditional Therapy
Therapists may try to use traditional approaches with autistic clients. Traditional therapy sometimes is not effective for autistic people. Just like much of the world, many therapists operate without the autistic neurotype in mind. Sound Mind Counseling wrote: “Traditional talk therapy often centers around social expectations, cognitive-behavioral strategies that assume a linear thought process, and interventions that can feel invalidating or even harmful for autistic people. The result? Many autistics leave therapy feeling misunderstood, frustrated, or worse—blaming themselves for a system that wasn’t built for them.”

Autistic people may face similar or the same neuronormative expectations in therapy that they already experience in the outside world.

Social workers may try to use approaches, which are considered to be highly effective. However, many evidence-based practices may not be effective with autistic people because they are geared towards neurotypical clients. These methods include the following:

• Cognitive behavioral therapy (CBT): CBT involves changing thoughts, and it is often thought to be the “gold standard” of therapy. Reportedly, CBT has assisted autistic people, decreasing anxiety. However, CBT may not be effective for some autistic people, who may find it to be “invalidating.” CBT is based on a neurotypical emotional processing method. Autistic people usually process information “bottom-up,” not “top-down.” CBT’s assumptions about cognitive distortions cannot be effective and can cause harm because autistic people tend to experience emotions and sensory input differently. CBT tries to normalize behaviors and reinforces camouflaging and conforming. Thus, from CBT, individuals can experience trauma and internalized ableism. Michelle Nidever, an autistic person, wrote, CBT’s “focus on cognitive distortions can make one feel dismissive of the very real systemic barriers, sensory challenges, and social dynamics we face daily. For autistic women especially, who often grapple with societal expectations of caregiving and self-sacrifice, CBT risks becoming another tool that tells us we’re not enough or we are doing it wrong.” She also wrote, “For autistic individuals, particularly women, masking is already a full-time job. We bend over backward to fit in, meet others' expectations, and take care of everyone else while quietly ignoring our own needs. CBT often reinforces this dynamic.”

• Strengths-based approach: Social workers are trained to use a strengths-based approach, which highlights positive aspects of their clients. While clients may like to be complimented, they may not benefit from this approach. Due to the world’s general intolerance of autistic people, autistic clients could struggle with seeing their strengths. In addition, their lived experience, especially if they are unemployed, may be that their strengths have gotten them nowhere. They may not be helped by a conversation about their strengths.

Treatment Seldomly Tailored to Autistic Clients
Many therapists do not tailor their work to their autistic clients since they follow neuro-exclusive practices they have been taught in school. For example, they may refrain from written communication, except for messages about scheduling and administrative topics. They may follow strict 50-minute sessions even though their clients may benefit from longer or shorter sessions. Social workers may also not adequately address clients’ sensory needs.

Application of Neurotypical Frameworks to Autism-Linked Behaviors
Therapists may apply neurotypical structures to address autism-related behaviors. Nathaniel Oldenburg, MA, LCPC, wrote that Jones, in The Autistic Survival Guide to Therapy, wrote about typical misinterpretations, including the following:

• “labeling needs for consistency or justice sensitivity as manipulative or narcissistic”;
• “mischaracterizing meltdowns as tantrums”;
• “interpreting alexithymia and executive functioning challenges as resistance or denial”;
• “dismissing pattern recognition and anticipatory dread as magical thinking or OCD”;
• “viewing sensory sensitivities as histrionic or emotionally stunted”;
• “seeing shutdowns or overwhelm as refusal or sulking”;
• “labeling stimming as anxiety”;
• “attributing the realities of neurodivergence to victim mentality or self-pity”;
• “misdiagnosing black-and-white thinking as borderline personality disorder”;
• “calling sensitivity to internal bodily experiences hypochondria”;
• “mistaking autistic burnout for chronic depression”; and
• “writing off irritability due to sensory hyposensitivities as a negative mindset or anger issues.”

The misinterpretations can cause mistreatment and bolster stigma.

Likewise, therapists could make the following mistakes about autistic people, as described by Pride in Self Consulting:

• “assuming lack of eye contact = disinterest or dishonesty”;
• “mistaking literal speech for sarcasm or rudeness”;
• “interpreting silence as avoidance or social discomfort”;
• “misreading monotone speech as boredom or hostility”;
• “expecting reciprocal small talk as a social necessity”; and
• “ignoring alternative communication methods (eg, AAC, scripting).”

These mistakes reinforce obstacles that autistic people may already face.

Final Thoughts
Learn more in my follow-up piece, entitled “Why Therapy May Not Always Help Autistic People: Part 2.”

— Miriam Edelman, MPA, MSW, is a Washington, D.C.-based policy professional.