I have been seeing a client in their 40s for three sessions now, and I strongly suspect that they might be autistic. However, they have not used the word themselves, although they have talked about being aware their brain ‘works differently to other people’s’. I don’t want to cause offence, but I believe that the client might benefit from having an assessment. I’m not sure how long they would have to wait for a diagnosis, though, or what resources they could access even if they were diagnosed. Should I suggest that they see their GP, or refer them on to a specialist therapist, or just not say anything about it?
Stephen Hitchcock, BACP’s Ethics Consultant, replies:
This is an ethical dilemma for which there is no single answer, and it would be unwise to generalise. Each client deserves to be met as a unique individual, and the danger of stereotyping is that we can become patronising and disrespectful, setting ourselves up as expert or seeing the other as ‘less than’. Some clients would take exception to the word ‘disorder’ in the commonly used term ‘autism spectrum disorder’ (ASD), with the implication that something is wrong with them and that neurodivergence is a problem.
The trouble with any formal diagnosis is that we can focus on the label and miss the person. Therapist Max Marnau, who has an autism diagnosis, says, ‘When you have met one autistic person, you have met one autistic person. We are just as varied as neurotypicals.’1
Even a seemingly innocent question such as ‘Have you ever considered being assessed?’ is bound to be interpreted by the client as ‘I think you should be’. So it is worth considering your motivation before broaching the subject, however tentatively. Seeing that this particular client has not mentioned autism, I wonder who would benefit from them seeking a diagnosis? If it is not an issue for your client, does it need to be an issue for you? Are you wondering whether it’s within your competence to work with a person who may be neurodivergent, or whether it’s more ethical to refer them on for a diagnosis?
A diagnosis could be liberating – some people report feeling massively relieved on being formally diagnosed. It may allow a client to make sense of their way of being, help them secure appropriate support and expect ‘reasonable adjustments’ to be made in their workplace. It may also be helpful and provide guidance for family members and those closest to your client. As one client said of their diagnosis, ‘It came as a huge relief. For my whole life, I had felt I was different – life wouldn’t fall into place for me.’2
However, the diagnosis process itself can be time-consuming and stressful, with no certainty of a positive outcome. Even if an onward referral were to be made and a diagnosis given, there is no guarantee that appropriate resources would be made available. There could be a long waiting list, with a lengthy delay between assessment and diagnosis, and the cost of a private assessment could be prohibitive. A client in their 40s is less likely to be able to access support than a young person.
If you are feeling inadequate when confronted by possible neurodivergence, you may feel convinced your client would be better served by being referred on. But you could be the right person to help them, and your feeling of insecurity is simply reflecting theirs. It’s also worth bearing in mind that your speculation about your client’s autism may be of limited relevance to the actual issues they want to bring to therapy.
Undertaking some CPD in order to understand neurodivergence better might help you feel sufficiently confident to continue working with this client and seeing where the work takes you both. It will also help you assess whether you are working within your competence, one of our most important commitments under the Ethical Framework (‘Our commitment to clients’, points 1b and 2a, and Good Practice, point 13). A search on BACP’s CPD Hub and Learning Centre reveals a range of relevant resources. As Max Marnau says: ‘If I [with autism] can work with neurotypical clients, you can work with autists… We need each other’s different perspectives, our different languages, our different ways of being in the world.’
One avenue of exploration could be around how the client thinks their brain ‘works differently’. Allow them to explain to you what that is like. You might need to make a special effort to create a safe space, making explicit what you are doing and how you are working as you go along. You could do your level best to enter into their world, to try to experience it as they do, and to help them feel less isolated and ‘different’ in what can seem a lonely world.
It’s also worth bearing in mind Elaine Nicholson’s reminder that it is not our job as therapists to pathologise autism: ‘We are there to listen, to emotionally hold, to gently assist the client to progress through their inner turmoil and conflict so as to help them.’3
Reader responses:
‘A diagnosis can help us find self-compassion’
As an individual who is now diagnosed as autistic, but went through life (and therapy) without knowing, I would encourage you to gently broach the subject when the time is right, rather than not mention anything to the client.
I would say from personal experience that once you have the understanding that you’re autistic, it potentially changes so many aspects of the self – processing past experiences, making sense of co-existing issues like anxiety and depression, and simply shaping the way you identify as the human being you are now.
Because autism is widely considered by neurodiversity-affirming individuals to be a neurology and a difference – our way of seeing the world, rather than a set of deficits – a diagnosis can help us find self-compassion, if we currently experience being misunderstood, maligned and marginalised as a non-diagnosed or non-autistic-identifying person. The realisation that one is autistic can essentially help individuals ‘find themselves’ in a truly authentic way (although that personal journey of acceptance and processing may take some time!), especially if they’re able to work with a neurodiversity-affirming therapist.
Additionally, a lack of authenticity can lead to ‘masking’, a form of camouflaging (often subconscious) that one undertakes in order to ‘pass’ in life and appear typical. This comes at great cost to autists, in terms of their emotional, mental and physical health. For example, the charity MIND reports that 94% of autists have experienced anxiety, while 83% have experienced depression. Eight times more autistic folk report feeling lonely than do the rest of the population, a situation that of course is also linked to mental ill health. Masking can even affect how an individual experiences and responds to therapy, and can vary between genders.
The waiting times for diagnosis in the UK can be lengthy (especially post-COVID), and the protocols for assessment do seem to vary within counties, and also between the four nations of the UK. A chat with the GP about the process in their locality would be a good first step. Some people are also happy to self-identify with whatever neurodivergence relates to them, and don’t feel they need a diagnosis, although they’d undoubtedly benefit from exploring what this neurodivergent identity means to them.
There are precious few resources available to diagnosed autistic adults, so they would be more likely to find support via local or online social groups, or private therapists. Feeling part of a tribe or community is a vital positive step for any marginalised individual.
Key aspects of the common autistic experience, such as sensory and nervous system dysregulation and socio-communicative differences, could be gently explored in therapy to see what the client’s perceptions of their experience are. I feel it is a therapist’s duty to educate themselves about possible neurodivergencies in specific clients, like this one, so that collaborative discussions can be undertaken and an honest and strengths-based dialogue can be introduced, in order to help the client discover their identity and autonomy.
Kathy Carter, Therapy Today Editorial Advisory Board specialist in autism
‘Autism is a fundamental part of a person’s self’
Don’t worry about referring at this early stage. Treat this client as you would treat any other client. Pick up what they say. Reflect it back. Listen. Respond. Get the feel of them. After three sessions, you barely know them.
Discover how they function, how their brain is different, what their experience of the world is. Ask them, ‘What do you make of that?’ If they say they feel like an alien, ask them what their planet looks like. Follow their lead.
Many non-autistic ‘specialist therapists’ are specialists in theory only; what they know is the medical model of autism – autism as a disorder, a deficiency, a collection of impairments. That approach is inevitable in the diagnostic process, but it is unnecessary and potentially very damaging in therapy and in life. Those specialists may know more about autism from outside than you do, but they do not know your client, and they do not know about autism from inside, which is what you, and your client, are discovering.
As a counsellor you are there to facilitate your client’s self-discovery, to facilitate their being the self that they truly are; and autism is a fundamental part of a person’s self.
If you have formed a therapeutic relationship and are working together, and after three sessions your client has already talked about their brain being different, then trust the process. You may find you don’t need to raise the question of autism; if it’s important to them, your client will do so themselves. But if, much later in the therapeutic process, it’s clear to you that you should, don’t worry about causing offence. Autism is simply a different, and minority, cognitive and sensory processing style.
Your client may or may not decide to go for an official assessment. For some of us, it is enough to recognise that we are neurodivergent; for others, a diagnosis feels important, or may be useful in education, work or other aspects of life. The choice is for your client, not for you.
I cannot overemphasise the importance of having done that work of self-discovery, of learning to prize one’s self before one faces the language of diagnoses, deficiencies, disorders, challenges and impairments of the diagnostic process; a GP is likely to have neither the time nor the understanding for that.
You will do that best by seeing their world from the vantage point of the client’s internal frame of reference, not that of your own theoretical expertise. Understanding autism from the autistic point of view may help, as you may pick up things that you would not otherwise notice; but it is more important to unlearn the stereotypes. If you are going to read or watch anything, choose something by autistic people, not by the non-autistic experts. There are plenty of books, articles and videos.
So when you begin to suspect that your client is autistic, don’t think, ‘Oh no, should I break the bad news to them, and if so, how?’; think, ‘Here is a chance for this person to discover something really essential about the self they truly are, to stop trying to be what they are not, and at last to play to their strengths.’
Max Marnau MBACP (Snr Accred), autistic person-centred counsellor and supervisor; founder of Autistic Counsellors and Psychotherapists Facebook group
‘Autism is not a condition to be cured’
Although it might seem sensible to encourage the client to see their GP to seek a formal diagnosis, I venture that, while it might be helpful for the therapist to know for sure, it would be too early for the client. For most autistic people I have known – including me – it takes a while to explore the possibility of being autistic. There is the gathering of information as well as managing doubts and disbelief (‘Yes, OK, but am I fully autistic?’). And even once convinced, it takes time to get used to the idea and realise what this means (and has meant) about your life and experiences, past, present and future. It may feel more comfortable for the client to do at least some of this exploring first, before seeking a diagnosis themselves to ‘make it official’. And there are some autistic people who do not wish to have an official diagnosis because there is no disorder to diagnose. Autism is not a condition to be cured – an autistic person is a human with a different neurotype.
However, not saying anything about autism or neurodivergence is not the answer, as it could give the message that a difference in neurotype either does not exist, is not significant, or is something that is not important. In my experience of working with autistic clients, it is hugely significant. I think of it in this way – a person is not a neurotypical with autism, they are a person for whom many, many things are different as a result of being autistic in a neurotypical world. And these differences will not only be those they recount in the stories they tell in the therapy room – the injustices, traumatic experiences, shame, grief and defensive strategies. They will also be those in the actual interactions with the therapist, and in the process of therapy itself.
It would be lovely if, on suspecting a client has autism, a therapist could sensitively and in a nurturing way hold that client while they explore the possibility and progress with the journey ahead, at their own pace, rather than setting the agenda for them. If the client feels safe and supported to explore their neurodivergence, they will be more likely to go on to own a new identity and form better strategies of how to operate in the world based on that reality.
And it may be natural for the client to seek a life that is more fulfilling once things make sense in a different way. That might mean, for the therapist, letting the client go when they need to find ‘their people’, which could well include an autistic therapist. My life has opened up in the past few years since finding a group of other autists like me – successfully independent, professional and sociable. Even though I have been a psychotherapist for 20 years, I’ve learned so much about life and myself from our talks. And it feels so good to feel the same things as other people, and to have had similar experiences. Autistic people do greatly benefit from being around other autists.
Vauna Beauvais, UKCP registered online therapist specialising in adults with autism and ADHD
‘A referral to a specialist may be appropriate’
Even without a mention of autism spectrum condition (ASC), a therapist noticing traits should nonetheless make suitable creative adjustments, in partnership with the client, allowing them to express and flourish. In addition, consistency provides predictability, making it easier for someone with ASC traits to maximise therapy. Of course, one size does not fit all – both neurodivergent and neurotypical people are on spectrums of differing needs.
As a neurodivergent counsellor, I am aware of the importance of a collaboratively agreed focus at assessment, along with a review point, to structure sessions. It helps to avoid a neurodivergent client feeling lost in the sea of exploration, adding more demands to the existing pressures of navigating therapy (a social situation). In therapy, clients may mask, or perform what they think may be required.
Incorporating a review provides a suitable juncture naturally leading into the possible causes for the initial concern, framed to delicately outline the possible reasons why this client’s brain ‘works differently from other people’s’. Potential additional questions could include: ‘What do you think could possibly be the reason for your brain working differently?’ ‘How do you think these sessions have helped towards understanding your initial concern?’
Pursuing an assessment may not necessarily be the next step. Although you may feel the client would benefit, it is important to ascertain what they think would benefit them. Researching autism together, psychoeducation and exploring how autism manifests specifically in the client’s life may be a better next step. Consider allowing the client freedom to explore subsequent steps at their own pace as this new information lands, to help them feel heard, understood, unashamed and accepted.
In my personal and professional experience, neurodivergent people often feel exhausted, judged and overwhelmed by continual daily demands. Hence I work creatively from a strengths-based model, with specific strategies tailored to that individual’s needs, drawing on their vast potential.
If a therapist feels ill-equipped, reading may prove to be helpful in the immediate term, but as with any presentation, the therapist should ensure they work within their competence as outlined in the Ethical Framework, otherwise a neurodivergent client’s experience of being misunderstood may be reinforced, perpetuating their anxiety. A referral to a counsellor with a specialism in neurodiversity may therefore be appropriate.
Iffat Shafiuddin MBACP (Accred) (she/her), counsellor working with children, young people and adults, clinical supervisor, manager and trainer
‘Be brave, be gentle and be sensitive’
I feel very strongly about this dilemma due to my own experience. When my son was 14, we realised that he probably had autism. I trod very gently when attempting to discuss with him the possibility of getting an assessment, but it led to a massive meltdown. I made a few more attempts over the years, but he could not take it from me.
As he was suffering badly with the anxiety and depression symptomatic of autism, I took my son to several different counsellors over the next seven years, desperately hoping that one of them would be able to form a strong enough therapeutic relationship with him to recognise (or at least suspect) ASD and be brave enough to bring it up. No one did.
Eventually, broken by pain and frustration, he reached the point where he was open to an assessment and was very quickly diagnosed on the NHS. This literally changed his life – it meant he could get the educational and financial support that he needed. It made things make sense to him and he is now comfortable with his neurodivergence. If one of those counsellors had done what I now do with my own clients, my son could have been saved many years of intense pain, shame and frustration.
My personal experience has enabled me to spot the signs of autism, particularly in males, and if I see enough signs, I will very gently enquire about whether they had ever considered it while making it clear to them that I’m not an expert and could be wrong. I work with adults and children and young people and have raised the question with clients from 12 to 59 years old without causing offence. No client or parent has ever had a problem with this. Most say that they were wondering about it themselves and would now arrange an assessment. Some said they ‘knew’ but didn’t feel the need for a diagnosis. Some wanted to explore the possibility and how they felt about it but not make it the main focus of their therapy.
For every client, it’s been like something inside just clicks, things suddenly make sense. Perhaps they were like me, just waiting for someone to say something. Perhaps by saying nothing we enforce within clients that it’s something so shameful that it should not be talked about.
As counsellors we can make an immeasurable difference to the lives of our clients who may be struggling with life because they are neurodivergent and trying to fit into a neurotypical world. So, if I see it, I say it, and I would encourage others to do the same. The dilemma writer asked three questions; here are my answers, based on my experience. Should they suggest the client see their GP? Yes. Should they refer them on to a specialist? If by that they mean a specialist autism counsellor, I’d say not unless the client asks them to. Should they say nothing about it? No! Be brave, be gentle and be sensitive.
Nicola Townsend MBACP, counsellor in private practice