Autism and trauma:
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How professionals unintentionally re-traumatise autistic children / teens / adults
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What professionals can do to support autistic people's mental health
No matter what intervention or level of input professionals provide, it's vital to give just as much consideration to HOW they're interacting and communicating with Autistic people. This is just as important (if not more important) as therapy goals, activities, tasks. The intervention is IN the relationship - without emotional safety, there are no therapy outcomes)
But why...?
...Because of trauma.
Autistic individuals have histories of trauma; children who end up in specialist settings / schools have typically experienced years of trauma due to being in mainstream schools that aren't set up for them. These children are punished for not being able to sit still or be allowed to move , they might be told off for messy handwriting and fidgeting, they may be punished for having poor attendance because their underlying distress is ignored and they're the ones who are blamed, instead of addressing the barriers in the environment that are causing this distress. When Autistic people aren't allowed to self-regulate or apply sensory strategies, this leads to worse mental health problems; we know that sensory processing and mental health are linked. They're taught to be 'resilient' and are often forced to tolerate distressing environments with the aim of increasing their sensory tolerance (known as desensitisation which is ineffective, painful and abusive).
The trauma of being triggered by the physical environment
Examples of inflexible rigid rules:
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no movement breaks
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no fidget toys
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no stimming because it 'distracts others'
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uniforms that are made of fabrics that trigger sensory overwhelm
Students breach school rules and behaviour policies because they cannot cope with the inflexible rules that schools impose on them. The irony being that autistic children are labelled as inflexible thinkers, yet they are placed in systems that impose inflexible strict rules. Students may fail exams because they can't access the curriculum as they simply cannot learn in the prescribed ways that neurotypical kids can and are labelled as 'stupid' or 'lazy'.
Autistic children are said to have rigid, inflexible thinking. The irony is that schools are the ones with rigid, inflexible rules.
Being repeatedly triggered by the environment to the point of sensory overload / meltdowns is its own type of trauma. This results in staff misunderstanding the child's distress who often react by punishing them, sanctioning them, labelling them as being 'challenging' or gaslighting them (telling them that how they think, feel and act is wrong when in fact it is completely understandable that how they feel is totally valid).
The trauma of being socially rejected
Autistic people often experience being socially rejected, teased and bullied by peers and adults, which in response, a set of coping mechanisms are learnt like masking which leads to devastating mental health problems. It's also common to observe Autistic young people use explicit language (swearing, racial / sexist language) in some social situations, which can be a form of masking and/or a way to seek control: "if I reject them before they reject me I'll be OK". But again, adults misunderstand the reasons for this language and label them as 'rude' and 'inappropriate', and having social deficits.
Some psychological therapies can re-traumatise Autistic people
Certain psychological therapies can inadvertently cause harm such as CBT (Cognitive Behavioural Therapy), MBT (Mentalisation Based Therapy), DBT (Dialectical Behavioural Therapy), or Exposure Therapy (desensitisation). Behavioural therapies (rooted in behaviourism) all share the goal of aiming to change how a person thinks, feels, and behaves. An underlying assumption is that the client has "faulty thinking" and "cognitive deficiencies or distortions" (or, 'mindblindness'). This also assumes that the therapist does not have 'faulty thinking', therefore, the way the therapist thinks, feels, and acts is 'correct'. In the context of Autism and working with Autistic people, this can be The Double Empathy Problem playing out in the therapy room if the therapist is neurotypical, which can be a problem because the professional won't know how it feels to experience the world as as an Autistic person does. This power imbalance and difference in neurology leads to inadvertent gaslighting and invalidation, ultimately worsening the client's difficulties and will inevitably lead to poorer self-esteem / mental health difficulties. When an Autistic person enters therapy and are told how they think, feel, and act is wrong, it repeats a historical trauma for that person because yet again there's another person in their life telling them they need to change. This is why the therapist needs to adapt therapies when working with an Autistic person.
What happens when Autistic people feel dismissed?
If the Autistic person feels unheard, ignored, and dismissed, then their trust with the adult is broken. Their shame will grow. They will continue to doubt their own reality and will think they're the one that needs to change. Their trauma may be unhealed. They'll continue to deny their own feelings because they've been conditioned to gaslight themselves. They'll continue to believe "what's wrong with me?" when these therapies aren't working and place the blame on themselves. The need to mask increases as a way for them to self-protect.
This is not to say that all of these therapies are equally as bad or damaging. As with a lot of interventions there will be components which might be helpful for the individual, depending on the nature of the problem they seek support for. A common phrase in recovery communities is "take what you like and leave the rest" and so adapting the therapy is crucial. E.g. DBT is often recommended for people with Borderline Personality Disorder (BPD) which the emerging research is showing that many Autistic women are being misdiagnosed with BPD due to the overlap of traits with autism (and stigma). DBT teaches self-regulation and sensory strategies to manage dysregulation, the ability to consider multiple perspectives at a given time, communication / assertiveness and self-advocacy skills. CBT for example might be useful in helping the person become aware of their internal scripts and schemas that may be contributing to their difficulties, and help the person begin to recognise that the way they talk to themselves isn't compassionate or nurturing.
Of course it's OK to help Autistic clients manage their anxiety and find ways to help them do the things they want to do. It's just about how this is done and the lens in which the Autistic person is viewed. You can help the person without invalidating and dismissing their thoughts and feelings and labelling them as 'cognitive distortions'. Learning to recognise feelings of excitement, sadness, anxiety and distress is important. Learning what your body feels like when you are in these states is important. Learning how to self-soothe, identify your triggers, and recognising thoughts that aren't serving you anymore is important.
Autistic children need Autistic role models. Finding a therapist who is Autistic (or neurodivergent) is a perfect match, and can be incredibly healing and powerful.
If neurodivergent therapists are hard to find then at least try to find someone who has a deep understanding of Autism and the intersections between trauma, sensory processing, cognition, marginalisation and victimisation.
How to provide an affirming, validating therapeutic space
Things to say / do:
Things to NOT say / do:
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VALIDATE their experience
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Affirm their reality
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"You have every right to feel that way"
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"What happened to you was not OK"
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"It's OK you feel [scared, anxious, worried]"
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Remind them it's OK to have needs
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"How did that make you feel?"
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"It's OK to-"
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Remind them frequently that they're enough
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Provide reassuring statements
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"Thankyou for telling me"
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Be consistent. Say what you mean. Mean what you say.
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Give them compassion and understanding
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Use a calm, gentle tone of voice
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"You're not responsible for other people's feelings"
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"What do you need?", "what can I do?"
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Allow silence / pauses
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"Take all the time you need"
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"I'm so sorry that happened to you"
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"That sounds really hard"
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"I can see you are [upset, struggling, finding this hard]"
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Be kind. Be patient. Build trust.
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Communicate your process, check you've understood: "what I'm hearing is", "have I got this right?"
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Don't try to fix, change, or give solutions
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"Don't be [silly / stupid / daft]"
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"I'm sure that person just meant-"
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Don't call them "high functioning"
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"You're too sensitive"
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Don't make assumptions / assign judgment
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Don't talk too fast
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Don't talk too much
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Don't touch without consent e.g. hand on their shoulder
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Don't minimise how they feel
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Don't dismiss their feelings
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"Replace that with a positive thought"
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Don't assign judgment to behaviour
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Don't talk over them / interrupt them
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"Just ignore it / them"
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"You'll be fine"
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"You overthink things"
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Don't compare their difficulties to other people's
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"I know how you feel"
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"You're overreacting"
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"You probably misunderstood"
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"You took it personally"
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"You just need to-"
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"It could be worse"
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"You just need to think positive"
