In early autism research and treatment, autism was considered a disorder or a disease that needed to be mitigated or cured. Its characteristics were presented as ‘symptoms’ and ‘deficits’, and treatment models focused on how to change the Autistic person to help them behave in more ‘typical’ or ‘normal’ ways.

A lot of work has been done in recent years to improve the way we understand and approach autism, writes researcher Sara Meyer. This began with the neurodiversity movement of the late 1990s, which challenged the medical model and deficit-based views of autism. The neurodiversity movement reframes autism as a form of neurodivergence—a difference among many differences in the way human brains work. According to this model, autism is simply a unique way of thinking, processing, communicating, and perceiving the world—a natural form of diversity that has intrinsic worth and value. It exists alongside many other ways of being in the world, some more common than others. It does not need to be judged, pitied, fixed, retrained, grown out of, or changed. 

Autism affirming approaches are simply approaches that acknowledge this reality and accept the Autistic person as they are without trying to reduce or change their Autistic traits. These approaches are also sometimes referred to as neurodiversity-affirming approaches or neuro-affirming approaches. 

How to ensure your practice is autism-affirming 

The saying “Nothing About Us Without Us” is central to disability advocacy. It affirms the right of Autistic people to have a say in research and practice that concerns them and to have their perspectives, preferences, and decisions taken seriously. Autism affirming approaches are those that centre the Autistic experience, rather than the experiences of the family members, professionals, and wider public around the Autistic person. Instead of aiming to ‘fix’ the Autistic person, services and supports should focus on improving access and quality of life for the Autistic person as they are. This emphasis is expressed in the Aotearoa New Zealand Autism Guideline: He Waka Huia Takiwātanga Rau (Third Edition), which notes that autism services and supports should accept Autistic people as authentically Autistic, presume competence and potential, and operate from a strengths-based lens.  

Recent research has aimed to consult more Autistic people about their experiences in clinical and therapeutic settings. Although more work is needed, current research highlights the following pointers for making your practice autism-affirming:   

 

One: Listen to Autistic people 

Listening to Autistic people can help inform your practice. While all Autistic people are different, there is often a lot they can connect on and a lot they wouldn’t understand about themselves without exploring their experiences together. Autistic adults, teens, and children can be an invaluable source of knowledge, perspective, and expertise. There are plenty of professionals who specialise in autism and other developmental conditions, but unless these professionals are Autistic themselves, they can never offer you the wisdom of lived experience as an Autistic person. 

When you are working with an Autistic person, an autism-affirming first step may be to seek out lived experience around the concern that your client is presenting with. You could look for blogs, articles, or research published by Autistic individuals to support this. 

This is important because it is not always easy for non-Autistic people to understand Autistic people. Often, Autistic experiences, emotions, and interpretations are misrepresented or ‘lost in translation’. A lot of things that Autistic people do can look one way on the outside, but when you ask what they were thinking or feeling, you might find that their intentions were quite different from what you were expecting.  

This is due to the double empathy problem. According to the double empathy problem, Autistic people have difficulty understanding the communication and perspectives of neurotypical people, and neurotypical people have difficulty understanding the communication and perspectives of Autistic people (Milton, 2012). This results in mutual disconnects and misunderstandings on both sides—but because Autistic people are in the minority of the population, they are often blamed when things go wrong. To be able to support an Autistic person in therapy or practice, it is essential to consider their perspective without making assumptions about what they are thinking and feeling. 

Here are some resources that might help you access Autistic perspectives: 

• Altogether Autism Journals 
• Reframing Autism – Understanding Autism 
• I am Autistic, by Chanelle Moriah 
• Different, not Less by Chloe Hayden
• Welcome to the Autistic Community, by the Autistic Self Advocacy Network. 

Similarly, when you consult research, think about how Autistic perspectives are represented in the studies you refer to. Autism-affirming research will have included Autistic people at every stage of the research process, and will feature Autistic participants. Aim to use work that centres Autistic voices and perspectives, rather than treating these as ‘optional extras’. 

 

Two: Adapt to Autistic communication styles  

Communication differences are a core diagnostic feature of autism. The differences that Autistic people typically experience can include:  

• Taking longer to use speech and language  
• Speaking less or not at all  
• Finding it difficult to speak in certain settings, but speaking fluently and easily in others (situational mutism)  
• Preferring written to spoken communication modes  
• Needing extra time to process verbal communication or instructions  
• Finding it hard to communicate what is wanted or needed  
• Interrupting or staying quiet because it’s hard to work out when it’s their turn to speak  
• Not understanding or wanting to engage in small talk—preferring conversation that is purposeful and based around sharing information  
• A preference for literal, direct use of language, as opposed to language that is more figurative or abstract  
• A preference for clear, non-ambiguous communication, as opposed to indirect communication through facial expressions, body language and gestures  
• Saying yes or agreeing to things to cover up their confusion  
• Over-analysing the conversations they have with others.  

A number of these differences can be accommodated in therapy sessions. You may, for example, decide not to start sessions with small talk, as this may seem confusing or pointless for the Autistic person. You may want to structure the sessions more clearly, so that they begin and end in the same way, or stick to conversation topics that the Autistic person enjoys. Having some pre-planned questions that you ask each time might be helpful. You can always check in with your client to make sure these questions are suitable and useful for getting the session underway. Sticking to a script may be reassuring for an Autistic client.  

In addition, many Autistic people prefer written communication to spoken communication, even when they can speak. They may need extra time to process verbal communication and / or instructions, find it hard to communicate their wants and needs, struggle with the ‘flow’ of conversation, use language in unusual ways, and experience high anxiety and rumination following conversations with others.  

In some cases, Augmentative and Alternative Communication tools (such as a tablet that turns typed words into spoken output) are required for therapy sessions.  

It is common for Autistic people to use multiple modes of communication. Anxiety may not always be the reasons these are used; sometimes, the Autistic person simply has a preference for non-spoken forms of communication in some settings. If alternatives are available, these may be preferable to trying to overcome selective mutism and increase speech in contexts where an Autistic person finds it difficult to communicate through speech.

Some options for supporting communication during therapy sessions include:  

• Electronic devices or apps that generate speech from typed language (e.g. Proloquo2Go; or contact TalkLink Trust for suggestions).  
• Allowing clients to explain their experiences and feelings through writing or drawing, rather than through speech, if they would prefer this.  

If you don’t know how a client prefers to communicate, it’s best to ask them. Even if they are able to use speech fluently, they may still prefer other methods. 

 

Three: Build a therapeutic relationship based on safety 

Autistic people are at greater risk for mental health problems than the general population. According to a Canadian review (Lai et al., 2019), the most common mental health conditions diagnosed alongside autism are:  

• ADHD (28% in this study)  
• Anxiety (20%—other studies have given much higher estimates)  
• Sleep disorders (13%)  
• Conduct disorders (12%)  
• Depression (11%)  
• Obsessive-Compulsive disorder (9%)  
• Bipolar disorder (5%) 
• Schizophrenia (4%)  

It is difficult to be sure of the reasons for this increased mental health stress, but Autistic people may struggle more than most because they live in a society that was set up for neurotypical, rather than Autistic people. The mismatch between Autistic needs and the environment they are in may create chronic stress and disadvantage, leading to heightened anxiety and depression. In addition, poor cultural understanding of autism, stigma, rejection, and exclusion have been shown to contribute to mental health difficulties (Pantazakos & Vanaken, 2023). Autistic researcher Kieran Rose has written about how Autistic people are often treated as ‘outsiders’, experiencing minority stress (2023).  

These findings point to a fragile and vulnerable Autistic population, often with substantial trauma. Many Autistic people then go on to experience further exclusion, rejection and judgment at the hands of mental health professionals (Crane et al., 2019). With all this in mind, it is important to build therapeutic relationships based on safety.  

Trauma-focused approaches are a helpful model for working with Autistic clients. The following tips may also help:  

• Modify the therapeutic environment to suit your client’s sensory needs and reduce anxiety  
• Follow a schedule or a structure to make sessions predictable  
• Ask your client about things that trigger them, and how you can help them cope. 
• Communicate clearly, literally, and directly 
• Listen to your client and act on the information they give you so that they know you are taking them seriously 
• Listen without judgment or pressure  
• Speak to your client with respect, expecting that they can understand you just like anyone else. Do not talk about them in front of them or assume that they can’t understand something 
• Don’t try to change their Autistic traits or preferences (this includes stimming, not making eye contact, or anything else that they do that is related to autism) 
• Base therapy around the Autistic person’s own goals 
• Uphold the autonomy of the Autistic person you are working with (Schuck, 2023).  

You can read further tips here: https://reframingautism.org.au/a-professionals-guide-to-supporting-autistic-clients-and-patients/ 

 

Four: Make your sessions a safe place where the Autistic person can unmask 

Many Autistic people, especially those that are diagnosed later on, go to great lengths to hide their Autistic traits and try to act like other people. They might imitate the way that other people talk, dress, and move, or change their interests to fit what is socially acceptable or popular. This process is also known as camouflaging.  

A study that was conducted with Autistic participants identified 38 kinds of masking or camouflaging behaviour (Cook, Crane, Hull, Bourne, & Mandy, 2022). Some common ones were: 

• Mirroring (copying the body language and mood of people you are talking to) 
• Forcing eye contact and smiling 
• Laughing frequently 
• Apologising or making excuses for perceived social errors 
• Seeking approval  
• Avoiding confrontation  
• Hiding or concealing information about oneself and one’s interests or preferences  
• Avoiding being honest or direct  
• Suppressing body movements and stimming.  

Other articles written by Autistic people talk about learning to copy facial expressions and emulate other people’s emotions.  

Masking is exhausting, and takes a massive toll on an Autistic person’s energy levels, mental health, and wellbeing. According to a survey of Autistic adults who regularly engaged in masking or camouflaging, most Autistic people experience masking as harmful and stressful. One key finding was that it made participants feel disconnected from their true sense of self, to the extent that many of them had no idea who they were at all. Masking was also associated with suppressing sensory needs and suicidal ideation (Miller, Rees, & Pearson, 2021). 

Unfortunately, it isn’t always easy or even possible for Autistic people to stop masking. All you can do is try to support them to be their authentic selves by creating a calm, accepting atmosphere that is free from judgment and pressure. If you can let your own guard down by showing your clients that you aren’t ‘perfect’, and that you aren’t going to freak out if they act Autistic, that could go a long way. Bear in mind that this may be a slow process for some clients. 

 

Five: Support Autistic people in building a positive Autistic identity  

Although the way we talk about autism has become a lot more positive and accepting, Autistic identity remains a battleground. Most Autistic people experience exclusion and discrimination in their daily lives, which may affect their sense of self.  

There is a powerful and ongoing need for language, practices, and habits that actively help Autistic people to build a positive Autistic identity, both as individuals and as members of a larger community.
 

Here are some ways you can help your clients build a positive Autistic identity:  

• Help them connect with other Autistic people and with Autistic perspectives and lived experience  
• Help them explore their unique strengths, abilities, and interests  
• Advocate for them, and encourage them to advocate for themselves  
• Learn about autism alongside your clients by sharing information and asking questions 
• Help them find ways to express themselves, whether these are alternative means of communication, art or music, or some other means.  

Although it can be challenging to support clients who think in ways you are not familiar with, taking an open-minded and curious approach will go a long way in ensuring your practice is autism-affirming. Be willing to ask questions, listen, make mistakes, and adapt. You may also want to explore ways you can upskill or access specific training or professional development to help you understand your Autistic clients better. As more and more mental health professionals ask for this kind of training and support, it is our hope that we will see better resources and opportunities emerge to meet this need.  

• Are you an Autistic person searching for a neuro-affirming therapist? Read this article to learn more Finding a neuro-affirming therapist – Altogether Autism

 

References 

Carbajal, J., & Praetorius, R. (2020). How does autism affect the processing of child sexual abuse trauma? Journal of Human Services: Training, Research, and Practice 5. 

Cook, J., Crane, L., Hull, L., Bourne, L., & Mandy, W. (2022). Self-reported camouflaging behaviours used by autistic adults during everyday social interactions. Autism: The International Journal of Research and Practice, 26(2), 406–421. https://doi.org/10.1177/13623613211026754 

Crane L., Adams F., Harper G., Welch J., Pellicano E. (2019). ‘Something needs to change’: mental health experiences of young autistic adults in England. Autism 23, 477–493. https://doi.org/10.1177/136236131875704 

Lai, M. C., Kassee, C., Besney, R., Bonato, S., Hull, L., Mandy, W., … & Ameis, S. H. (2019). Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis. The Lancet Psychiatry, 6(10), 819-829. 

Miller, D., Rees, J., & Pearson, A. (2021). “Masking Is Life”: Experiences of Masking in Autistic and Nonautistic Adults. Autism in Adulthood: Challenges and Management, 3(4), 330–338. https://doi.org/10.1089/aut.2020.0083 

Milton, D, (2012) On the ontological status of autism: The ‘double empathy problem’. Disability & Society, 27(6). 

Pantazakos, T., & Vanaken, G. J. (2023). Addressing the autism mental health crisis: Tthe potential of phenomenology in neurodiversity-affirming clinical practices. Frontiers in Psychology, 14, 1225152. https://doi.org/10.3389/fpsyg.2023.1225152 

Pearson, A., Rose, K., & Rees, J. (2023). ‘I felt like I deserved it because I was autistic’: Understanding the impact of interpersonal victimisation in the lives of autistic people. Autism, 27(2), 500-511. 

Schuck, R. K. (2023). Moving toward neurodiversity-affirming services for autistic individuals: Social validity, autistic perspectives, and measuring attitudes (Doctoral dissertation, University of California, Santa Barbara). 

Singer, J. (2016) NeuroDiversity: The birth of an idea. Kindle. Retrieved from  https://www.amazon.com/NeuroDiversity-Birth-Idea-Judy-Singer-ebook/dp/B01HY0QTEE/ 

Walters, S., Loades, M. & Russell, A. (2016). A systematic review of effective modifications to cognitive behavioural therapy for young people with autism spectrum disorders. Review Journal of Autism and Developmental Disorders, 3, 137–153 . https://doi.org/10.1007/s40489-016-0072-2