Therapy is a place to be heard and understood, yet for many autistic adults, building a sense of psychological sanctuary can be tricky. Mental health support is especially important due to heightened prevalence of depression, anxiety, and suicidality in the autistic population (O’Nions et al., 2024).
For autistic clients, the differences in communication style, sensory processing, need for structure and the experience of masking, can all influence how therapy is received and whether it feels safe. Critically, the lack of informed understanding and tailored approach are the two main barriers for accessing therapy among autistic individuals (Adams & Young, 2020). Therefore, for a therapist, the challenge lies in turning autistic experiences into opportunities for tailored support, rather than allowing them to become sources of misunderstanding. Without these considerations, even the most carefully nurtured therapeutic relationship may wither.
To meet the needs of autistic clients, we need to move beyond assumptions and ground therapy in autistic people lived experiences. While emerging literature highlights the value of flexible, autism-informed approaches (Mazurek et al., 2023), a more in-depth exploration is required to understand what truly helps in practice.
A study by Pappagianopoulos et al. (2024) sought to address this gap and translate the lived experiences into practical recommendations for clinical practice. Their research also aimed to replicate previous findings on experiences of mental health support (e.g., Brede et al., 2022) with a larger sample.
A tailored approach grounded in autistic experiences is essential for delivering therapy that is both acceptable and effective.
Methods
Nineteen formally diagnosed autistic adults aged 21-50 (mean age 30.9) took part. All participants had prior experiences of therapy, and almost all had at least one co-occurring mental health condition, most commonly anxiety, depression and ADHD. The sample was predominantly adults formally diagnosed with autism, aged 21-50 (mean age 30.9), white (79%) and included some diverse gender identities (26% trans/non-binary).
Semi-structured interviews were conducted via Zoom, lasted 1 hour and were video recorded. This method was favoured over focus groups due to less overwhelm. An interview guide allowed for elaboration while addressing the research aims. The guide questions tapped into the most and least helpful therapy elements, as well as recommendations to make therapy more helpful. Participants also filled out a demographics survey.
Reflexive thematic analysis followed Braun and Clarke’s (2006) framework, employing an inductive approach. This allowed for data-driven semantic analysis and interpretation of participant experiences (Braun & Clarke, 2019).
The researchers acknowledged professional experiences of working in therapy/research with both autistic and non-autistic individuals, as well as personal experiences with family members.
Appropriate ethical approval was obtained, and the issues of informed consent, confidentiality, participant compensation and funding information were discussed accordingly.
Additionally, the study was designed in line with the recommendations from the Academic Autism Spectrum Partnership in Research and Education (AASPIRE), e.g., participants were given an opportunity to review the interview questions beforehand. The authors were also mindful of the autism-specific language preferences, using identity-first language to honour participant preferences.
Results
Three overarching themes and eight sub-themes were generated, reflecting crucial therapeutic approaches discussed by participants.
1. Cultivating a safe space informed by an understanding of autism
Therapists should have knowledge of autism, avoid assumptions, and challenge biases. For participants, it was important that their masking experiences and strain were recognised. Additionally, feeling valued and validated was imperative for building a trustful therapeutic relationship. It was important for a therapist to have a non-judgemental approach and offer genuine interest.
Meanwhile, invalidation, condescension, and dismissal of concerns negatively shaped the experiences, highlighting the need for more autism-specific training for therapists.
2. Demonstrating a flexible and collaborative approach responsive to clients’ needs
Communication needs could be met by allowing alternative methods, such as writing, visuals, and structured prompts. Guided, as opposed to vague/open questions were seen as more helpful, as was reduced eye contact.
Sensory needs included fidgeting, doodling, and movement, and adapting therapy to avoid sensory overload (e.g. reschedule during noisy construction).
Offering practical predictable routines, previews of the next sessions, and having different options for the therapy setting (e.g., text-based chat) enabled structure and comfort.
As for the therapy content, alignment with the clients’ goals and asking for feedback fostered collaboration. Also, ‘homework’ was seen as something that needs to be reframed depending on whether the client perceives it as helpful or stressful.
3. Considering clients’ preferences around talking in session
Many participants found talking openly (“info-dumping”) therapeutic and cathartic; while others found repetitive talk frustrating if no solutions were offered. Overall, therapeutic work was most valued for giving new perspectives, reassurance, and honesty. Ultimately, having a space to talk as well as problem-solve was seen as a helpful approach.
Through the lens of autistic individuals, successful therapy combined autism-informed understanding with responsiveness to unique needs and preferences.
Conclusions
This study reinforces existing research on therapy experiences among autistic individuals, highlighting the crucial role of autism-informed clinical practice. The identified themes emphasise specific aspects of therapy that can be adapted to better meet autistic clients’ needs. While the findings align with general recommendations for effective clinical practice, they particularly underscore the importance of delivering tailored psychological support. Additionally, the results suggest potential avenues for enhancing clinical training and improving mental health services for autistic people.
The study calls for further investigation of ways in which autistic individuals can access and receive tailored mental health support.
Strengths and limitations
The study’s qualitative methodology enabled a fruitful investigation of therapy experiences, painting a detailed picture how therapy can be adapted to reflect and meet the needs of autistic adults. As a reader, I saw a clear link between the research aims, the methods used, and the findings, which reflects an overall meaningful coherence of the study. Additionally, I appreciated that selected quotes and their quantity directly supported the themes, creating credible and highly relevant results.
Importantly, the study bears some limitations. Firstly, the sample was “homogenous in terms of racial and ethnic identity and limited to independent adults with the ability to verbally describe their experiences” (Pappagianopoulos et al., 2024, p. 9). This means that the needs captured in the study may not reflect therapeutic experiences of other groups. Additionally, the authors acknowledge that the details of the exact therapy modalities (as well as therapy quality) were not considered. It would indeed be important to explore this facet of mental health support, to reflect not only the diverse needs but also the approaches to therapy.
Also, while reflexivity was mentioned, I was curious to know more about the reflective practice that the researchers employed and how their experiences as clinicians shaped their interpretations of the data. The researchers also note the limitations of the retrospective nature of the interviews and the associated recall bias. However, I wonder if, to some extent, this prompted a more holistic reflection on the overall therapeutic journey.
It would have also be beneficial to include autistic researchers and/or participants in co-analysing the results to ensure multivocality. That said, the researchers brought in some autism-centred considerations by following AASPIRE recommendations for research design and being respectful around language preferences. Additionally, analyst triangulation was employed during the analysis, ensuring good inter-rater reliability. Overall, the study addresses a highly timely and practically relevant topic.
Blogger’s note for this section: Tracy’s (2010) “Big Tent” Criteria were kept in mind when evaluating this study.
This study offers a coherent and credible exploration of autistic adults’ therapy experiences, but involvement of autistic individuals in the research process is needed to enhance authenticity and multivocality.
Implications for practice
The findings call for autism-informed therapist training on communication and sensory needs, as well as the impact of masking. Flexibility and collaboration are some of the key therapist qualities that appear central to not only being informed about autism, but also delivering therapy in an accessible and acceptable format. Specific ways in which therapy can be adapted include offering practical strategies and seeking feedback on what is/isn’t working. Ultimately, the overarching implication for clinical practice is ensuring tailored support for autistic individuals on top of the general non-negotiables of good therapy practice. I am intrigued by the avenues that open for further re-imagining of the therapeutic relationship to meet the needs of autistic people.
At the level of policy and service design, autism-specific training may need to become a professional standard to ensure consistency across mental health services. Addressing this gap requires more than individual goodwill: it demands systemic change in clinical training, supervision, and organisational culture. Healthcare services could also embed autism-friendly adjustments, such as quieter waiting rooms, shorter sessions, and/or tailored interventions, in order to create a safe and comfortable space that accounts for sensory needs.
Supporting autistic individuals requires more than a few minor tweaks – getting to know the lived experiences is imperative for a validating and effective therapy.
Statement of interests
No conflict of interest to declare.
Links
Primary paper
Pappagianopoulos, J., Brunt, S., Smith, J. V., Menezes, M., Howard, M., Sadikova, E., … & Mazurek, M. O. (2024). ‘Therapy through the lens of autism’: qualitative exploration of autistic adults’ therapy experiences. Counselling and Psychotherapy Research, 25(2). https://doi.org/10.1002/capr.12861
Other references
Mazurek, M. O., Pappagianopoulos, J., Brunt, S., Sadikova, E., Nevill, R. E. A., Menezes, M., … & Harkins, C. (2023). A mixed methods study of autistic adults’ mental health therapy experiences. Clinical Psychology & Psychotherapy, 30(4), 767-779. https://doi.org/10.1002/cpp.2835
O’Nions, E., Brown, J., Buckman, J. E. J., Charlton, R. A., Cooper, C., Baou, C. E., … & Stott, J. (2024). Diagnosis of common health conditions among autistic adults in the uk: evidence from a matched cohort study. The Lancet Regional Health – Europe, 41, 100907. https://doi.org/10.1016/j.lanepe.2024.100907
Brede, J., Cage, E., Trott, J., Palmer, L., Smith, A., Serpell, L., … & Russell, A. (2022). “We have to try to find a way, a clinical bridge” – Autistic adults’ experience of accessing and receiving support for mental health difficulties: a systematic review and thematic meta-synthesis. Clinical Psychology Review, 93, 102131. https://doi.org/10.1016/j.cpr.2022.102131
Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa
Braun, V. & Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health, 11(4), 589-597. https://doi.org/10.1080/2159676x.2019.1628806
Tracy, S. J. (2010). Qualitative quality: eight “Big-Tent” criteria for excellent qualitative research. Qualitative Inquiry, 16(10), 837-851. https://doi.org/10.1177/1077800410383121
