Therapy When You Are Autistic

Does talking therapy work for autistic people?

Yes. Slightly less well than it does for everyone else, and the reason for that gap matters.

The largest study covers NHS Talking Therapies in England. It looked at more than two and a half million adults who had at least two sessions. Of those, 8,761 had an autism diagnosis.

The study paired them with comparable non-autistic clients. Of the autistic adults, 56.1 per cent reliably improved, against 61.7 per cent of the comparison group.

That is not a small number and it is not a failure. It does mean autistic clients did somewhat less well. It also means 9.2 per cent got worse, against 7.2 per cent of others.

We could leave that number out. We would rather say what we think it means. That service was not designed with you in mind.

A five-point gap looks much more like a design problem than a verdict on you.

Source: El Baou et al. 2023

What NICE says

There is a common assumption that autistic people need a different kind of therapy. That is not the guidance.

The national guidance for autistic adults is clear on the point:

For autistic adults and coexisting mental disorders, offer psychosocial interventions informed by existing NICE guidance for the specific disorder.

The same therapy. What changes is how it is delivered.

Source: NICE CG142

The adaptations NICE expects

The guidance sets out the changes it expects. You are entitled to ask for these. They are not favours.

• A more concrete and structured approach, using written and visual material such as worksheets and diagrams
• More emphasis on changing behaviour than on changing thoughts, using behaviour as the starting point
• Rules made explicit, with the reason for them explained rather than assumed
• Plain English, avoiding heavy use of metaphor, ambiguity and hypothetical situations
• Involving a family member, partner or friend to support the work, if you want that
• Regular breaks, and using your own interests in the work where that helps

The guidance also expects the professional to understand autism and its effect on treatment. Where they are unsure, it expects them to seek specialist advice.

Adjustments to the room itself are a separate matter, covered separately in the same guidance. We have put them on their own page, because they are the most practical thing you can ask for.

Source: NICE CG142

Mental health, and a number worth understanding

Among autistic adults, pooled research puts lifetime depression at around 37 per cent. Lifetime anxiety comes out at around 42 per cent.

Now compare that with what appears in medical records. Researchers have also counted only confirmed clinical diagnoses. On that basis, depression appears in 11 per cent of autistic people, and anxiety in 20 per cent.

Researchers read that gap as under-diagnosis rather than disagreement. A great many autistic adults are anxious or depressed and have never had it recognised.

UK primary care data supports that reading. Take autistic adults without a learning disability, compared with similar non-autistic adults. Anxiety was recorded around 1.9 times as often, and depression around 1.8 times.

Sources: Hollocks et al. 2019, Lai et al. 2019, O'Nions et al. 2024

Masking, and what it costs

Masking means managing how you come across so that other people are comfortable. It takes many forms.

• Suppressing stimming
• Rehearsing conversations before you have them
• Copying expressions that do not come naturally

Research finds a measurable link between camouflaging and both anxiety and depression. The link holds after age and autistic traits are accounted for. The effects are real but modest, so we will not overstate them.

People who mask in some settings and not others report anxiety and stress as high as those who mask constantly. We have written more about masking on its own pages, including autistic burnout.

Masking is also part of why so many people arrive at this question late. A 2023 study of English primary care records found that 0.82 per cent of people had an autism diagnosis. Its authors estimated that between 59 and 72 per cent of autistic people did not.

The same 2023 analysis found that the rate falls sharply with age. Among 10 to 14 year olds, 2.94 per cent had a diagnosis. Among people over 70, it was 0.02 per cent.

Those people did not stop being autistic. They were never recognised.

Sources: Hull et al. 2021, Cage & Troxell-Whitman 2019, O'Nions et al. 2023

What to look for in a professional

You are looking for someone who adapts without being asked twice. In practice that means a few concrete things.

• They answer practical questions directly, including about the room, the format and what happens in a session
• They will put things in writing if you ask
• They do not treat literal answers as resistance
• They are comfortable saying what they do not know about autism
• They understand that a calm exterior is not evidence that you are fine

If you have tried therapy before and it did not work, say so at the start. It is common, and it is usually information about fit rather than about you.

If things are bad right now

Autistic adults are recorded with self-harm around twice as often as comparable non-autistic adults. If you are struggling badly tonight, please do not wait for a therapy appointment.

Our crisis page lists free confidential helplines you can contact today. You do not need to be in danger to use them. You do not need to use us at all.

Source: O'Nions et al. 2024