Welcome to Healing is my Special Interest, the newsletter at the intersection of late-diagnosed autism and healing from high control environments. Today’s guest post is a really special one, because it’s by my partner! I might be biased but he is literally the best man to ever exist. In his own private practice he is a model of always being open to learn more information to better understand the people he is trying to help. Krispin wants the world to be the tiniest bit easier for autistic folks, and that means changing the culture of a lot of mainstream therapy! Check out his website here, and as always, thank you so much for supporting, sharing, and liking these posts. We couldn’t do this work without you :)
TWs: Ableism in Therapy, Mental Health Outcomes for Undiagnosed Autistic People
The Dangers of: “I Don’t Work with Autistic Clients”
Guest post by Krispin Mayfield, LPC
I used to be one of those therapists who said, “I don’t work with autistic clients.” But the truth was, I was working with them — I just didn’t know it yet. Through the diagnosis of autistic family members1, I learned about autism beyond the stereotypes from grad school and outdated perceptions that were incredibly common among therapists. And as I learned about autistic individuals, I began to recognize that many of my clients (both current, and those I’d worked with previously) were also autistic, and I’d just missed the signs.
The majority of us therapists have been undereducated and under-trained on how to identify and support autistic individuals. Typically, we receive either little training about neurodivergence, or out-dated information, and we haven't done our homework to update our framework. Yet, autistic folks reach out to therapists every day for support. They’re hiding in plain sight, undiagnosed, in therapy offices everywhere.
I wasn’t alone in using the refrain, “I don’t work with autistic clients.” I have heard it often from other therapists throughout the years. Yet the reality is that most of them likely do work with autistic clients who simply haven’t been identified as autistic yet. A study in 2022 found that many clients experienced a gap of 11 years between first seeking mental health support and receiving an autism diagnosis2. For many, that means engaging in therapy for over a decade before anyone recognized their autistic traits. Studies show that women often mask their autistic traits significantly more in a clinical setting and often go undiagnosed while they are undergoing therapy3. More recently, many believe this dynamic is not limited by gender, and there are autistic folks of all genders that have become adept at masking their autistic traits — at great impact to their mental health4.
Studies show that Autistic people are twice as likely to seek therapy services, compared with the general population5. Yet, while they are more likely to seek out therapy, therapists are less likely to provide care to them. One study interviewed nearly 500 therapists and found that over half of them, if given the option to work with an autistic client, would refer to another provider who has more knowledge about autism6. This limits the access that autistic clients have to finding a therapist who can support them.
Autistic clients often engage in therapy asking for support with anxiety, depression, eating disorders and more. Yet, when their therapist doesn’t understand how being autistic in a neurotypical-privileged world often contributes to mental health, it can limit the effectiveness of the therapy. Sometimes it can even be harmful, (according to a report by the Royal College of Psychiatrists in 2020)7.
Eight years ago, when I started working at an ADHD clinic, I specifically listed autism as a condition that I didn’t work with clinically. I find this tragic now, considering that recent research shows that nearly 1 in 4 ADHDers also meet criteria for Autism Spectrum Disorder (using DSM-5 guidance). Back then, there was very little information about the overlap between ADHD and Autism, and we assumed that because someone had a diagnosis of ADHD, it was incredibly unlikely that they were also Autistic.
There's a reason for that. Until 2013, according to guidance from the American Psychological Association, mental health professionals could not diagnose ADHD and Autism at the same time. This is a startling fact, and it means that prior to 2013, all the professionals who specialized in ADHD, by definition, never worked with autistic clients — and vice versa. So once someone was diagnosed with ADHD, all the autistic traits were considered to be part of their ADHD diagnosis. The way we thought about it back then was something like this: this client has ADHD, AND they really like a rigid structure for their day to help their executive functioning. They struggle with [neurotypical] social interactions because ADHD has kept them from learning social skills. They have a lot of sensory sensitivities, and they get super passionately hyper-fixated on certain interests, but that’s just because they’re ADHD. If you’re familiar with Autistic traits, you know that everything I described all fit under the autism umbrella of traits. But the reality is that in my field of mental health, we looked at everything through an ADHD lens without an updated understanding of Autism.
I remember reading Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, which was the gold standard for research on ADHD. It’s one of those textbooks that they call a “handbook,” but if you carry it with only one hand, you’d likely sprain a wrist. It’s over 800 pages with encyclopedia-type font. The edition I have was published in 2014, and if you look in the index, you’ll find a total of four references to autism. One of those references cites a study indicating that it’s estimated that between 10-30% of ADHDers are also Autistic. Yet, the books says basically nothing else about diagnosis or care of Autistic people. Books like these are authored by those who’ve dedicated their whole career to diagnosing and caring for people with ADHD — and have very little (if anything) to say about working with Autistic clients.
Whether we're treating anxiety, depression, eating disorders, or other diagnoses, as a field, many mental health professionals have done a very poor job of considering the possibility of Autism for our clients. Fortunately, researchers are beginning to investigate how often Autistic traits go overlooked among different clinical populations. They’re asking questions like, “if we assessed all the women in an in-patient eating disorder clinic, how many would be autistic?” (spoiler: the answer is more than a third).
Here are some more examples the dangers of people not being assessed or diagnosed as Autistic:
ADHD: As mentioned before, A 2022 study found in a group of 56 adults diagnosed with ADHD, 23.3% also met criteria for Autism Spectrum Disorder. That’s nearly 1 in 4 ADHDers who also fit criteria for Autism Spectrum Disorder.
Substance Use Disorders: It’s estimated that 1 in 5 teens and young adults in addiction treatment have undiagnosed autistic traits. Autistic folks are twice as likely to develop a substance use disorder compared to allistic (non-autistic) peers8.
Eating Disorders: One study assessed for autistic traits among women that were receiving inpatient care eating disorders, and they found that 35% of the women assessed were autistic9.
[Suicide warning] One study in the UK reviewed clinical files of people who had died by suicide, and found that over 1 in 10 people were likely undiagnosed autistics10.
We therapists have a duty to update our understanding of autism, and at the very minimum, regularly use screening tools to assess the possibility of autistic traits. There is tremendous gain to be had when mental health professionals are open to new insights. I tell my clients regularly that one thing I love about being a therapist is that there’s always exciting new things to learn about — and understanding autism is one of those areas.
Unfortunately, research about autistic folks continues to lag because of the outdated understanding that continues in the psychological and academic community. I’ve found that the best places to learn about autism are from the autistic community, including both lay autistic folks sharing their experiences, as well as research led by autistic professionals. I've learned the most from my autistic clients, especially in therapy groups, where they have a chance to share and compare their experiences of everyday life11.
Though it’s relatively small, there is new research being done to give us an updated picture of what it looks like to be autistic, and what it can look like outside of the stereotypical research based on white males — a broader picture of what it means to be autistic for BIPOC, women, trans people, and more. My favorite part of discovering this new research is the care that is often given for accessibility — whether it’s the fact that it’s freely accessible, like the article “No Way Out Except from External Intervention: First-Hand Accounts of Autistic Inertia”12 or the inclusion of an easily-understood abstract, like in ‘Autistic person’ or ‘person with autism’?
There are a number of neuro-divergent-affirming resources that therapists can (and should!) use to help identify and support their autistic clients:
In 2023, Donna Henderson, Sarah Wayland and Jamell White released a set of two books that are incredibly practical for clinicians, titled Is This Autism?
Dr. Megan Neff has invaluable clinical resources at their website, Neurodivergent Insights. My favorite section of the website is Misdiagnosis Mondays which creates clear infographics regarding differential diagnoses.
The Autism Partner Handbook by Joe Biel, Elly Blue & Dr. Faith G. Harper is helpful for anyone wanting to learn about autism from a neurodivergent-affirming approach.
Embrace Autism is a website that provides easy access to empirically validated screeners and assessment tools — and they do a great job of identifying strengths and weaknesses of different assessment tools. Any clinician can easily use this resource with their clients.
There are several podcast episodes with experts in identifying autism in adults, like this episode on the testing psychologist.
And that’s just the start. As a psychological community, we have failed our Autistic clients in the past. As resources for therapists continue to be developed, I hope to see positive mental health outcomes for all neurodivergent people. I belief that if people in the field of mental health continue to update our understanding, we will be able to provide the support our Autistic clients have always deserved.
Krispin Mayfield is a therapist in Portland, OR, specializing in supporting neurodivergent couples and individuals, as well as those recovering from religious trauma.
D.L. here: I feel like this is such an important topic, because when mental health professionals refuse to do their work and learn more about autism, it impacts the lives of so many people. AND it directly contributes to poor mental health outcomes! My personal belief is that you can tell a lot about a therapist based on their willingness to be open to current research and learning from the lived experiences of marginalized people. If they aren’t open to either of those two things, then run far, far away!
I will say I am heartened that a lot of younger therapists are very open to learning and to new research, which is great. But we need so many more people doing this work, especially in the field of mental health.
Let us know what you think: was it easy or difficult for you to find a mental health therapist that was comfortable talking to you about autism? How long were you in therapy before autism was brought up?
*D.L. here (that’s me!!!!!!!)*
Technically, 11 years was the median amount of time in the study
(Attwood 2007; Gould and Ashton-Smith 2011; Lai et al., 2011)
*D.L. here: and meeeeeeeeee!*
Many of my AuADHD clients have told me this research is some of the most validating literature they’ve read.
Thank you for writing this.
I just read the graphic novel, Button Pusher, and found it to be such a moving story--I would love to know if you've read and what you thought of it!
Love this! Thanks for creating this great resource.