A Qualitative Study Investigating the Positive Experiences of Therapy and Therapeutic Relationships of Late-Diagnosed Autistic Females

Abstract

Background:

Autistic adults face a paradox: they have a greater risk of developing mental health difficulties, while also experiencing increased barriers to accessing mental health care. Research on reducing these barriers has previously focused on physical adjustments such as providing quiet waiting rooms, and cognitive adaptations such as using unambiguous language. Approaches to building the therapeutic relationship have been under-researched.

Methods:

The researchers interviewed 12 UK-based late-diagnosed White autistic females about experiences of therapy that they identified as being particularly positive. The study adopted a critical realist and neuro-affirmative stance, with an insider researcher position. The researchers developed common themes and subthemes through reflexive thematic analysis.

Findings:

Three themes were developed from the interviews and incorporated eight subthemes. Theme 1: “Providing and delivering beneficial therapy for autistic clients” included “sourcing therapy” and “autistic expectations of positive therapy.” Theme 2: “Features of a positive therapeutic relationship from an autistic perspective” included “building trust and rapport,” “equitable power dynamics,” and “reciprocity and a collaborative approach.” Theme 3: “Understanding autism and using adaptation strategies” included “adaptation strategies,” “understanding autism,” and “positive autism.”

Conclusions:

While physical and cognitive adaptations improve the accessibility of therapeutic interventions, therapists must also focus on adapting the therapeutic relationship with autistic clients, particularly with an enhanced focus on power dynamics and collaborative approaches. All participants described positive experiences of connection when their therapists shared relevant insights and experiences to build common ground. Recognizing less stereotypical presentations of autism and exploring internalized ableism in both the therapist and client improved the positive experience of therapy.

Community Brief

Why is this an important issue?

Autistic people have identified mental health as a major issue, with only a small percentage of those wanting support being able to access it.

Previous research has recommended adjustments to the physical environment and adjustments for thinking and processing styles, but therapists need more information about building positive therapeutic relationships with autistic clients.

What was the purpose of this study?

This study sought to identify best practices in therapy by listening to the experiences of autistic adults who felt that they had received particularly positive support. By focusing on a smaller subgroup of autistic people, late-diagnosed autistic females, we aimed to identify commonalities to provide specific recommendations to therapists.

What did the researchers do?

We interviewed 12 late-diagnosed White autistic females about their experiences of therapy that felt particularly positive. We compared their answers and developed common ideas.

The researchers offered interviews in a variety of formats to cater to autistic communication differences, either live via video link or live chat, or over more extended periods via email or voice messages. Eleven of the 12 participants chose email interviews.

What were the results and conclusions of the study?

We analyzed the interview answers and developed them into three main themes. Theme 1: “Providing and delivering beneficial therapy for autistic clients” includes the subthemes “sourcing therapy” and “autistic expectations of positive therapy.” Theme 2: “Features of a positive therapeutic relationship from an autistic perspective” includes the subthemes “building trust and rapport,” “equitable power dynamics,” and “reciprocity and a collaborative approach.” Theme 3: “Understanding autism and using adaptation strategies” includes the subthemes “adaptation strategies,” “understanding autism,” and “positive autism.”

What is new or controversial about these findings?

Participants described wanting therapy to feel challenging but also to provide a nonjudgmental and validating space. They emphasized a need for an enhanced focus on collaboration and appreciated therapists who were willing to share some of their own insights and experiences to build common ground. This study also suggests that therapists needed more information about autism and its wider presentation, and should recognize and challenge internalized biases and ableism within themselves and their clients.

What are potential weaknesses in the study?

This study was limited to a UK population and only looked at late-diagnosed White autistic females. Further work needs to be done to explore the experiences of the wider autistic population, including other minority groups, those with learning disabilities, and those who do not communicate with speech.

How will these findings help autistic adults now or in the future?

Improving therapists’ knowledge of autism and appropriate therapeutic adaptations can improve therapy outcomes and reduce health care inequalities within the autistic population. Offering multiple communication formats for participation in scientific research promotes accessibility, allowing a greater number of autistic individuals to contribute to future studies.