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Why Therapy May Not Always Help Autistic People: Part 2
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.

This piece follows-up on my prior piece, entitled “Why Therapy May Not Always Help Autistic People: Part 1.” A main reason why autistic people have problems in therapy is the dearth of training of social workers on disabilities.

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

Fear of Potential Autistic Clients
Social workers may be fearful of suicidal thoughts and behavior of autistic people. They may be afraid of a lawsuit that could result from a suicide. Failure to prevent suicides is the most frequent malpractice claim.

As a result of fear, social workers may refuse to take on, as a client, an autistic person who has suicidal thoughts. They may also abruptly terminate service to an autistic client and may not even have a last termination meeting. This treatment may be traumatic to an autistic client, potentially reminding them of past firing(s) from jobs. It may also cause the client to have increased suicidal thoughts and/or behavior. Their lived experience would now include even mental health professionals, who are supposed to help with mental health, refusing to assist.

Social workers also may be afraid of a potential autistic client’s desire for revenge. They may even be concerned that taking on that person as a client may cause that client to seek revenge on them. That fear could be reasonable, as a major piece of information that the social worker could know about the person is that the individual wants revenge. It is conceivable that the potential client may want revenge on others, including their mental health professionals.

Misdiagnosis Leading to Provision of Inadequate Treatment
Social workers may not adequately serve their clients. The therapists could give them the wrong diagnosis, invalidating their experiences. Since the mental health professional misdiagnosed them, their treatment plan may not fix their client’s real issues. For example, a therapist could diagnose a client, who actually has unspecified trauma and stressor-related disorder, with just depression. Thus, at the end of most sessions, the therapist could ask the client about the client’s plans for the next week. Asking about plans may try to get the client to be active, but it is not an adequate intervention for their client’s actual mental health conditions.

Frustration With Autism-Related Written Communication Causing Therapist to Use Artificial Intelligence in Emails
Traditional therapy centers on regularly scheduled oral conversations. However, many autistic people prefer written communication. It may be easier for autistic people to express themselves through writing than oral discussions. They may email their therapists, potentially overwhelming the therapists and causing the mental health professionals to think that the clients need support.

Without the clients' knowledge, therapists could use AI as part of their email program and/or through an AI website (potentially putting clients' personal information at risk) to summarize clients' emails and/or to reply. If therapists use a summary and do not read the clients' email, they could miss key points, causing autistic clients to wonder why they did not get a response to those portions. If therapists respond via an AI-generated email (either completely or partly—therapists could revise the AI-generated draft reply, which they then send to the client), autistic people, who may be good at pattern recognition, may suspect that their therapists are using AI.

The use of AI in emails could produce the following negative reactions: "surprise, confusion, shame, disappointment and, crucially, a loss of trust." Damages could be especially profound on autistic people, as this AI practice may a send a message that like many others, even their own mental health professionals think they are difficult.

Concerned that their emails could be met with AI-created replies from their therapists, autistic clients could email less, losing out on crucial support. Needing support, they could begin to rely on AI websites even though AI created the initial problems. They could justify it because they know AI is AI while they would not expect AI to come from their own therapists. Use of AI as a supplement to therapy could lead to greater social isolation and incorrect and inadequate assistance.

Therapeutic relationships may not survive the breach of trust from the use of AI. The autistic clients or the therapists may choose to end their working relationship.

Irritation by Clients’ Other Autistic-Related Behavior Leading to Termination of Care
Social workers conceivably may get exasperated by their clients’ autism-related behavior. For example, they may not like their clients’ written communication and may try to force the client to change how they communicate, potentially traumatizing their client. In addition, therapists may be distracted by their client repeatedly rocking back and forth. They may initially think that they could handle the physical motions, but later get so bothered by it that they end service.

Social workers may get irritated with their clients’ being triggered by simple words. They may find it challenging to avoid commonly used words that have negative connections for their clients. As a result, they may terminate service, which could traumatize clients.

Lack of Acknowledgement of Therapist’s Ableist Views
Therapists may not recognize their ableist views. Autistic psychologist Megan Anna Neff says, “When therapists have not yet deconstructed autism narratives and worked through ableist and allistic-centered beliefs, they often reenact doer-done-to dynamics with their autistic clients.”

Dismissal of Autism Diagnosis
Therapists may wrongly dismiss their client’s diagnosis. A person said: “My therapist told me I was 'emotionally stunted' and to 'stop obsessing' about having ADHD because it didn’t define me … when in fact it completely changed my life, connected me to people who understood, and furthered my self-understanding as a now-identified AuDHDer.”

Lack of Autism Diagnosis
As some people receive a late autism diagnosis, autistic people may be in therapy but not know they are autistic. In such situations, frequently, mental health professionals “attribute autistic traits to PTSD, anxiety, depression, or early childhood trauma.” When symptoms but not the underlying autism are discussed, clients may feel that “there was something wrong with them” or may not feel understood.

Chrysta Bairre, who is autistic, said: “By only focusing on my trauma, my lived experience as an autistic woman was overlooked, invalidated, and minimized, which reinforced many of my childhood experiences of being invalidated and minimized when I showed autistic traits and behaviors.”

Inadequate Handling of Hearing Late About Autism Diagnosis
Through meeting with their client, a social worker may learn that their client may be autistic. It is possible that the client had not disclosed their autism right away or that the client became aware of their autism through a late diagnosis during the time they are having therapy. Once finding out that client is autistic, a social worker may refuse service because they may feel that they cannot help autistic people. Thus, the social worker terminates services, causing harm to the client.

Lordnibbler16 wrote online: “My best friend is a therapist so I get to hear her side often. She knows I'm autistic and loves me and has no judgement towards me. She has told me of a handful of cases where a client was diagnosed with ASD or another diagnosis that she isn't competent in and she ends the relationship. I know she does a better job of explaining it to the client so they don't feel hurt but still, she knows she has to end it. She also said in some cases she can refer to another therapist but other times she can't based on the diagnosis or her employment contract.”
“She feels that she isn't the best-suited person to help with ASD and is horrified of doing more harm than good. She has imposter syndrome and can lack confidence and doesn't ever want to do anything that she feels she isn't qualified for.”

Comments and Questions That May Worsen Situation
According to neuerodiversity expert Bridgette Hamstead, therapists may make comments and ask questions that may exacerbate, not improve, their client’s situation. Hamstead identified remarks, which she explained. Those comments include the following:

• “You’re not trying hard enough.” The client may have tried, doing everything that they were supposed to do, but all that trying has led them nowhere.

• “That’s just anxiety. Everyone has anxiety.” As Hamstead wrote, “Many therapists miss the signs of autistic distress because they do not understand sensory overwhelm, social exhaustion, or autistic shutdown. Instead, they frame everything through an anxiety or depression lens. When we explain our overwhelm, we are told it is just anxiety. When we explain our discomfort with eye contact, we are told it is just social anxiety. This framing erases the root of our distress and pressures us to ‘push through’ instead of honoring what our body is trying to tell us.”

• “Let’s talk about how you can be more resilient.” According to Hamstead, “Resilience is a word often used to place the responsibility for survival back on the person already struggling. AuDHD women are already resilient. We have been adapting, translating, and enduring for years. What we need is not more pressure to bounce back. We need environments that do not keep knocking us down. Framing resilience as a moral imperative implies that burnout is a failure of character, not a predictable outcome of chronic mismatch between needs and environment.”

• “It sounds like you’re overreacting.” This comment is blaming the client, who may have been told for much of their life that they are too difficult. This remark is akin to gaslighting.

• “Why don’t you just ask for help?” The client may have learned from experience that it is unsafe to ask for assistance. As Hamstead wrote, “Asking for help is not simple when you have a history of being punished or dismissed for needing anything. For many late-diagnosed women, asking for help has meant being met with control, rejection, or loss of autonomy.”

• “What would happen if you just stopped masking?” This question could show little to no comprehension of masking. The client may mask in order to survive.

• “Try not to think in black-and-white terms.” The client may think in such ways because they need clarity. If a social worker makes such a comment, the therapist invalidates a coping mechanism.

• “You need to take more responsibility.” This comment puts the onus on the client, who already may blame themselves for all. It repeats hurtful messages that the client may have heard about being too challenging.

• “Let’s focus on solutions, not problems.” Social workers may think they are trying to motivate the client, but such a comment frequently silences the client. The client may need to discuss their challenges before they can improve.

Inability to Help Assist Clients in Ways that Would Actually Benefit Them
Although social workers want to help their clients and may connect their clients to resources, they may not be able to assist in certain ways that would improve their clients’ mental health. For example, social workers cannot secure employment or remedy revenge for clients. Since the autistic clients’ needs may not be met, the clients’ mental health may worsen even if they are in therapy.

Final Thoughts
Social workers should not fail autistic people as many may have and should not be too afraid to take on autistic people as clients. Instead, social workers should take advantage of courses in school, continuing education trainings, conference sessions and workshops, and more to learn about autism and how to treat autistic patients.

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