Autistic Women: Bridges & Barriers in Counselling & Psychotherapy
By Linda Tuxford-Adams
Video Description: We as Autistic Women & Non-Binary need support but many providers lack the requisite cultural humility and neuro-cultural competence (Wisehart, 2024) we require. This video is an attempt to ‘uncloud veiled eyes’ in an era when many practitioners believe themselves to be affirming after a 2-hour training delivered by a neurotypical ‘Autism expert’ with content formulated usually without appropriate consultation with lived experience educators and narratives.
I argue that in the same way our professions require us to adopt a stance of non-knowing with First Nations peoples, BIPOC, LGBTQIAP+ and CALD clients and demand we commit to developing cultural competence-so should we approach the neurodivergent experience (inclusive of Autistic experience) as a culture.
The term Neuro-Cultural Competence emerged from an Autistic Professionals Discussion group at the Reframing Autism Community Summit and will henceforth be credited to KJ Wiseheart (2024). The discussion was rich and nuanced and highlighted our professions already have the conceptual framework to accommodate Autistic understandings more respectfully but there seemed to be this block when it comes to Autism and really any other difference in neurology framed by the pathology paradigm of the DSM.
Not respecting a person’s culture and demanding they conform to ours within the therapeutic framework would be immediately ‘red flagged’ as harmful if not traumatising by our governing bodies. So this insistence with Autistic clients on ‘making atypical more typical’ and inflexible application of neurotypically designed and field-tested theories and techniques without adaptation stubbornly persists is honestly beyond me.
The consulting with neurotypical ‘Autism experts’ too is elitest and honestly there is much better out there. Check out Sonny Jane Wise Lived Experience Educator (in this presentation) for a start. Within our fields are many talented Autistic professionals as well. No need to bring in outside consults-look within your own ranks.
I challenge counsellors and psychotherapists to get curious, adopt an attitude of cultural humility and learn from Autistic persons and lived experience educators to develop Neuro-Cultural Competence. Our clients deserve better-so let’s do better.
The transcript and images are below.
The neurodiversity paradigm describes Autism as one of many natural neurological variations in human diversity (Chapman & Botha, 2023; Pantazakos, 2023; Saxe, 2017). The social model of disability reframes difficulties experienced by Autistic people as primarily due to living in a world where acceptable ways of being and doing are defined by the neurotypical majority (Cage et al., 2018; Chapman & Botha, 2023; Smart & Smart, 2006).
There are 205,200 diagnosed Autistic people in Australia. That is 1 in 100 with a gender ratio of 1 female to every 4 males (ABS, 2015; Jones et al., 2021; McCrossin, 2022). However, evidence suggests females are greatly underrepresented due to diagnostic bias and unfamiliarity with non-stereotypical presentations of Autism (Bargiela et al., 2016; American Psychiatric Association, 2022; McCrossin, 2022; Mo et al., 2021; Riedewaan & Zaman, 2022).
Thus, Autistic females are diagnosed later, in adulthood or self-diagnose due to socio-economic barriers and health care provider ignorance (Adams, 2022; Belcher et al., 2023; Hens & Langenberg, 2018; Huws & Jones, 2013; Murphy et al., 2023; Rujeedawa & Zaman, 2022; Stagg & Belcher, 2019). The social construction of Autism as white, male and socially awkward marginalises those who present differently resulting in limited presence in research and support development and barriers to support access (Belcher er al., 2023; Blackmore et al., 2017; Hamilton, 2019; Huws & Jones, 2013; Jones et al., 2020; Lopez, 2022; Seers & Hogg, 2021; Wilson et al., 2023).
It has been additionally proposed that Autistic women often go undiagnosed due to their highly developed ability to camouflage, mask and assimilate making them harder to detect (Belcher er al., 2023; Blackmore et al., 2017; Cage et al., 2018; Hull et al, 2019). Unfortunately, this has long term debilitating effects and often leads to misdiagnosis when mental health support is sought (Au-Yeung et al, 2019; Gesi et al., 2021; Hull et al., 2019; North, 2023).
The intersectional effects of being an Autistic, female, and an adult makes ones’ needs without a frame in neurotypical minds (Cascio et al., 2021; Crenshaw, 2015; Lopez, 2022; Saxe, 2017; Seers & Hogg, 2021). However, the lived experience of Autistic women is quite real, and research demonstrates that multiple intersectional effects make each individual’s experience qualitatively different and unfortunately more invisible to being effectively acknowledge and supported by health professionals (Abubakare, 2022; Ames et al., 2022; Digard et al., 2022; Heylens et al., 2018; Hours et al., 2022; Jones et al, 2020; Kelly et al, 2021; Lilley et al., 2020; Nolte et al., 2021; North, 2023; Reuben et al., 2022; Rumball et al., 2020; Weir et al, 2021)
Autistic women may have less obvious communication difficulties than males, but they are much more likely to have debilitating sensory sensitivities (Talcer et al., 2023; Huang et al., 2022). Furthermore, due to a tendency to internalise emotional pain, Autistic women are at greater risk for mood disorders, disordered eating, self-harm, domestic violence, suicide, PTSD and co-occurring health conditions (Adams & Young, 2021; Au-Yeung et al., 2019; Belcher et al., 2023; Blackmore et al., 2017; Cage et al., 2018; Camm-Crosbie et al., 2019; Cusack et al., 2016; David et al., 2022; Leedham et al., 2020; Maddox et al., 2022; Malik-Soni et al., 2022; Peterson et al., 2019; Reuben et al., 2021; Reuben et al., 2022; Rujeedawa & Zaman, 2022; Rumball et al., 2020).
Barriers in Counselling & Psychotherapy
A history of misdiagnosis, invalidation and misinterpretation causes Autistic women to mistrust that counsellors can understand and support their needs (Adams & Young, 2021; Harmens et al., 2022; Leedham et al., 2020; Lipinski et al., 2022; Murphy et al., 2023; Seers & Hogg, 2021; Tint & Weiss, 2018). This anticipation of misunderstanding and mis-attunement significantly hinders the establishment of rapport (Hallet & Kerr, 2020; Hodge, 2013; Pantazakos, 2019).
Autistic women report counsellors lack of knowledge regarding the lived experience of Autism and their lack of skill and experience acts as an additional barrier (Hallet & Kerr, 2020; Lipinski et al., 2021; Murphy et al., 2023). The use of pathologizing language further derails connection (Bury et al., 2023; Han et al., 2021; Nicolaidis et al., 2015). On the therapists’ side, misconceptions, outdated assumptions, and implicit biases regarding Autism are also problematic (Dickter et al., 2020; Hallet & Kerr, 2020; Hodge, 2013; Jones et al., 2021; Lipinski et al., 2021).
Also, unfamiliarity with Autistic communication styles, body language and ways of regulating leads to counsellor’s misidentifying internal states (Hallet & Kerr, 2020; Milton et al., 2022; Mitchell et al., 2021). When these therapist factors are unexamined, counselling’s inherent power dynamic magnifies their influence and impedes relationship building (Hume, 2022; Jellett & Flower, 2023; Pantazakos, 2023).
This also potentially causes harm as they can lead to faulty case conceptualization and ineffective treatment choice (Brede et al., 2022; Leedham et al, 2020; Milton et al., 2022; Mitchell et al., 2021).
Further significant barriers include counsellor inflexibility in treatment approach and the counselling environment (Adams & Young, 2021; Camm-Crosbie et al., 2019; Hallet & Kerr, 2020; Tint & Weiss, 2018).
A ‘deficits focus’ where ‘fixing’ is prioritized over relational safety undermines self-acceptance and causes trauma (Gillespie-Lynch et al., 2017; Leadbitter et al., 2021; Leedham et al, 2020; Hume, 2022; Pantazakos, 2019). Counselling focused on changing to fit societal norms reinforces ableist assumptions that Autism is undesirable (Robertson, 2010; Leadbitter et al., 2021). Rigid application of any approach without taking into account differences in Autistic neurology is highly problematic (Adams, 2022; Adams & Young, 2021; Brede et al., 2022; Cooper et al, 2008; Hahamy et al., 2015; Tint & Weiss, 2018).
In addition, the counselling environment and the structure and behavioural expectations of sessions can be barriers for Autistic women (Adams, 2022; Hallet & Kerr, 2020). Specifically, the sensory environment, seating arrangements, not understanding many Autistics need for movement and the discomfort of eye contact can make the counselling room unwelcoming (Camm-Crosbie et al., 2019; Hallet & Kerr, 2020).
Overall, the barriers of mistrust, lack of knowledge, outdated assumptions, implicit bias and communication differences hinder the establishment of rapport. Deficit –focused interventions and unadapted therapy approaches further invalidate. The environment and structure of counselling may also hinder Autistic women from engaging successfully in counselling.
Bridges to Counselling & Psychotherapy
However, there are bridges to address these barriers and to facilitate a working relationship. The first bridge focuses on the person of the therapist and the development of cultural humility. This includes learning from the lived experience of Autistic adults, self-reflection, exposure to Autistic culture and understanding the bidirectional nature of communication difficulties (Bulluss, 2021; Jellett & Flower, 2023; Milton et al., 2022; Mitchell et al, 2021; Morrison et al., 2020).
Many approaches to working with Autistic people come from an outside perspective (Jones et al., 2021). Lived experience-driven theories, narratives, and education empower counsellors to offer informed, neurodivergence-affirming counselling (Bulluss, 2021; Gillespie-Lynch et al., 2017; Jellett & Flower, 2023). To address implicit bias and ableism, counsellors must commit to developing cultural humility through self-reflection and learning from Autistic narratives, culture, and community (Bulluss, 2021; Gillespie-Lynch et al., 2017; Hodge, 2013; Jellett & Flower, 2023; Wright, 2019).
The double empathy problem explains Autistic and non-Autistic communication breakdowns as due to differences in communication style (Bulluss, 2021; Jellett & Flower, 2023; Milton et al., 2022; Mitchell et al, 2021; Morrison et al., 2020). Diffusion chain studies on this point have found communication within neurotype is effective, whilst mixed neurotype communication often breaks down (Crompton et al., 2020). It is important that neurotypical counsellors accept the mutual responsibility for meaning making needed for respectful cross-cultural communication (Bulluss, 2021; Jellett & Flower, 2023; Milton et al., 2022).
The second bridge focuses on ensuring counselling practice is neurodivergence affirming (Cooper et al., 2018; Chapman & Botha, 2023). Firstly, phenomenological and feminist lenses have been recommended to ensure equitable counselling for Autistic women (Pantazakos, 2023). Additionally, strengths-based approaches focused on self-acceptance, self-compassion, and embracing Autistic identity have been found to enhance well-being (Adams, 2022; Bureau & Clément, 2023; Harmens et al., 2022; Hens & Langenberg, 2018; Kelly et al., 2021; Leadbitter et al., 2021; Leedham et al., 2020; Wilson et al., 2023).
Various adaptations exist to support with co-occurring conditions, but implementation should prioritize relationship-building, be trauma-informed, neurodivergence-affirming, individualized, and collaboratively executed to prevent harm (Brede et al., 2022; Cage et al., 2018; Chapman & Botha, 2023; Cooper et al., 2018; Dickson et al., 2021; Hume, 2022; Lipinski et al., 2022; Murphy et al., 2023; Pantazakos, 2019; Reuben et al., 2021). Given Autistic diversity, approach selection should resonate, ensure relational safety, support preferred expression, and align with personal goals (David et al.,2022; Dickson et al., 2021; Murphy et al., 2023; Reuben et al., 2021; Reuben et al., 2022; Rumball et al., 2020; Späth & Jongsma, 2020).
Sensory audits and being aware of client’s sensory profile is important for comfort and engagement (Bulluss, 2021; Camm-Crosbie et al., 2019). Checking in regularly and being flexible with allowing the use of art materials, fidgets, self-regulatory tools, alternate seating, and movement are helpful accommodations (Hallett & Kerr, 2020). Providing outside, online, and text-based options will also make counselling more accessible.
In conclusion, whilst there are significant barriers, counsellors can develop both themselves and the therapy context to facilitate inclusivity and support Autistic women. The relational nature of counselling is conducive to fostering the safety, connection and support desperately needed by this vulnerable population. It also has the potential to nurture the wellbeing and empowerment of Autistic women.
Autistic Educators & Artists in video:
Sonny Jane Wise: https://www.livedexperienceeducator.com/
Dr Megan-Anne Neff: https://neurodivergentinsights.com/
Amy Adams: https://www.findingautism.com.au/
Jolanta Tucker: https://www.instagram.com/jlepsiokowa
Neurodiverse Family: https://www.etsy.com/au/shop/NeuroDiverseFamily
About the Author
Linda Tuxford-Adams is an AuDHD Integrative Counsellor, Educator, Group Facilitator, Researcher and the Founder of Neurokindred. They specialise in providing individualised, neuro-affirming, trauma-sensitive mental health support for late-identified Autistic adults particularly particularly those perceived female at birth with complex trauma. Within her field, Linda is committed to increasing neuro-cultural competence in mental health practice and community work settings. She also truly believes in the efficacy of connection to the Autistic community through peer and discussion groups as conducive to Autistic well-being.
Her academic contributions include ‘Emotional job demands and emotional exhaustion in teachers’ in Educational Psychology, presentations on bridges and barriers to counselling & psychotherapy for Autistic women, Words That Dance: Finding My True Self Through the Masks and the “Mania” with Reframing Autism, as well as insightful pieces illustrating neuro-affirming application of therapeutic approaches on Neurokindred.