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Abstract

There is growing research interest in examining how cultivating autistic adults’ self-compassion may improve their mental health and overall well-being. However, caution is needed in applying compassion-based therapies to autistic adults due to the phenomenon of backdraft, which is an intense, distressing reaction that can occur during self-compassion practices. Autistic individuals, often burdened with trauma and past adverse experiences, may be particularly vulnerable to backdraft. Preliminary research indicates that a large proportion of autistic adults report experiences of backdraft, indicating a significant potential for adverse short-term effects. This Perspective piece provides a brief overview of self-compassion and backdraft, highlights why backdraft is particularly relevant to self-compassion research involving autistic adults, and offers recommendations on how to study backdraft and clinically support autistic adults through their backdraft experiences. We advocate for research into the mechanisms of backdraft in autistic adults and stress the importance of trauma-sensitive therapeutic approaches. We also recommend that clinicians proactively address backdraft and provide the necessary support to ensure these therapies remain beneficial. This perspective underscores the importance of understanding the unique challenges autistic individuals face during self-compassion and compassion-based therapies and calls for rigorous research and clinical strategies to mitigate the risks associated with backdraft.

Keywords

autism backdraft self-compassion compassion-based therapies recommendations

The autistic community is currently facing a mental health crisis (Mandy, 2022). Although autistic adults experience significantly higher rates of anxiety, depression, and other mental health challenges compared to the general population (Hossain et al., 2020; Hudson et al., 2019; Lai et al., 2019), many do not have access to adequate mental health services (Croen et al., 2015), due to reasons such as lack of autism knowledge of therapists and treatments not fit for purpose (Adams & Young, 2021; Camm-Crosbie et al., 2019). In a previously published Perspective article in Autism in Adulthood, Cai and Brown (2021) proposed that cultivating self-compassion could be a valuable complementary approach to supporting the mental health of autistic adults—now embraced by the autistic community as a strength-based approach. This proposal was rooted in the understanding that self-compassion may promote resilience by improving people's ability to regulate their emotions. Around the same time, two preliminary studies by Howes et al. (2021) and Galvin et al. (2021) examined the relationship between autistic traits, self-compassion, and anxiety and depression in general population samples. These studies revealed that autistic traits were negatively correlated with self-compassion and that self-compassion may mediate the relationship between autistic traits and mental health symptoms.

Since the publication of these early papers, nearly a dozen empirical studies have emerged exploring the self-compassion experiences of autistic adults, with findings indicating that autistic adults self-report lower levels of self-compassion than non-autistic counterparts (Cai, Gibbs, et al., 2023; Galvin & Richards, 2023), and higher levels of self-compassion are associated with better mental health outcomes through its interactions with emotion regulation and camouflaging in autistic adults (Cai, Love, et al., 2023; Galvin, Aguolu, et al., 2024). Through interviews, Wilson et al. (2023) found that women experienced reduced self-criticism and greater self-kindness after receiving an autism diagnosis. Furthermore, using a longitudinal design, Galvin, Howes, et al. (2024) showed that self-compassion predicted subsequent symptoms of anxiety and depression in autistic adults. Preliminary evidence shows that self-compassion interventions improve self-compassion and mental health outcomes and reduce self-stigma (Cai et al., 2024; Edwards et al., 2024; Riebel et al., 2024). Together, these research findings indicate that the self-compassion levels of autistic adults are malleable, and treatments focused on cultivating self-compassion are likely to improve mental health. Given the growing interest in this space and as research moves more and more into intervention work, we urge researchers to proactively examine backdraft experiences in the current Perspective piece because these experiences are often associated with self-compassion practices.

We bring together different and unique perspectives in this paper. Cai is a Research Fellow at Aspect (Autism Spectrum Australia) and Senior Research Fellow at the University of Melbourne, currently leading a program of research aiming to increase the self-compassion levels of autistic adults and parents of autistic children. Outside of her research work, she mentors autistic and non-autistic adults to cultivate their self-compassion using compassion-focused therapy (CFT) and mindful self-compassion (MSC). She has been a long-term practitioner of compassion-based approaches. Galvin is an Assistant Professor at the University of Warwick, where he leads the Warwick Self-Compassion Program for Autism (WiSPA), a research initiative focused on increasing self-compassion in autistic adolescents and adults. Drawing from his research, work in the community, and lived experience as a family member, Galvin seeks to improve the mental health and quality of life of autistic individuals through compassion-based approaches. Through our research findings, conversations with autistic adults, and contemplative practices, we have come to appreciate the importance of cultivating self-compassion to improve autistic people's resilience and mental health.

When we recently met to discuss our shared interests, it quickly became apparent that while compassion-based approaches hold potential for autistic populations, our research and clinical experiences highlighted a specific therapeutic challenge that might be particularly relevant to autistic populations: the backdraft phenomenon. We hope this Perspective article will help introduce the concept of backdraft to the autistic and autism community, especially clinicians and researchers who support autistic adults. We aim to (1) provide a brief overview of self-compassion and backdraft; (2) highlight the reasons why we think backdraft is particularly relevant to self-compassion research of autistic adults; (3) provide recommendations on how to research backdraft and clinically support autistic adults through their backdraft experiences.

Self-Compassion

Self-compassion is being kind and understanding toward oneself during times of failure, suffering, or perceived inadequacy (Neff, 2003a). It involves treating oneself with the same care and concern that one would show to a good friend, and it consists of three core components: self-kindness, common humanity, and mindfulness (Neff, 2003b). Research on self-compassion has shown that it is associated with numerous psychological benefits, including reduced anxiety and depression, increased emotional resilience, and greater overall well-being (Brown et al., 2021; Cleare et al., 2019; MacBeth & Gumley, 2012; McArthur et al., 2017; Shattell & Johnson, 2018; Zessin et al., 2015). Studies indicate that individuals who practice self-compassion are better equipped to handle life's challenges, demonstrating more adaptive coping strategies and improved mental health outcomes (Ewert et al., 2021). A meta-analysis of randomized controlled trials (RCTs) found that self-compassion interventions improved eating behavior, self-compassion levels, and mindfulness and reduced rumination, stress, depression, anxiety, and self-criticism (Ferrari et al., 2019). Furthermore, self-compassion predicts physical health, specifically in global physical health, functional immunity, composite health behavior, sleep, and danger avoidance (Phillips & Hine, 2021).

Interventions to improve self-compassion typically focus on cultivating mindfulness and fostering a compassionate mindset through various structured programs. The MSC program, developed by Neff and Germer (2013), is an 8-week course combining mindfulness meditation practices with exercises to enhance self-kindness and recognize shared human experiences. CFT, created Gilbert (2014), integrates principles from evolutionary psychology, cognitive-behavioral therapy, and mindfulness to help individuals alleviate self-criticism and shame by developing a compassionate inner voice. CFT not only incorporates self-compassion theory and practices, but it also targets giving compassion to others and receiving compassion from others (three flows of compassion). Both MSC and CFT incorporate loving-kindness meditations that direct feelings of love and compassion toward oneself and others. There is strong evidence for MSC across various populations (Bluth et al., 2016; Neff & Germer, 2013; Neff et al., 2020). For instance, Torrijos-Zarcero et al. (2021) conducted an RCT of MSC for chronic pain patients and found that MSC may result in greater benefits on self-compassion and emotional well-being than cognitive behavioral therapy. Similarly, the evidence for CFT is strong—a recent systematic review and meta-analysis of CFT with clinical populations found the therapy to be effective for improving self-compassion, self-reassurance, self-criticism, fear of self-compassion, depression, and eating disorders (Millard et al., 2023).

Other non-compassion-specific interventions that overlap with some of the key self-compassion principles and practices include dialectical behavior therapy (DBT) by Linehan (1993a, 1993b), which emphasizes mindfulness and self-acceptance, and acceptance and commitment therapy (ACT; Hayes et al., 1999), which encourages individuals to accept their thoughts and feelings without judgment and commit to value-aligned actions. These diverse programs offer unique strategies to help individuals develop a kinder, more understanding relationship with themselves, significantly improving mental health outcomes (Delaquis et al., 2022; Powers et al., 2009; Yadavaia et al., 2014).

Backdraft and its Purpose in Healing from Past Hurts and Trauma

Although the long-term health and well-being benefits of self-compassion practices are indisputable, many individuals who engage in these practices may initially encounter adverse reactions, known as “backdraft” (Germer, 2009, 2023; Germer & Neff, 2013, 2015, 2019). Backdraft is a phenomenon that occurs when individuals experience an increase in emotional pain or discomfort as they begin to practice self-compassion. It is often likened to the sudden rush of heat and flames when a door or window of a burning room is opened, symbolizing the release of repressed or unacknowledged emotions that can arise when one starts to offer kindness and care to oneself. Backdraft may present as negative and critical thoughts, unpleasant emotions such as shame or anger, body sensations like pains and aches, and challenging behaviors such as aggression or withdrawal (Neff & Germer, 2022).

Neff and Germer (2022) suggest that backdraft is an integral aspect of the transformative nature of self-compassion. As a result, experiencing backdraft may be an unavoidable part of healing and recovering from past wounds and trauma. Sadly, most children and adults have experienced at least one form of adverse childhood experiences or trauma (Holmes et al., 2021; Swedo et al., 2023); hence, many people are likely to experience backdraft when they first start self-compassion practices. Backdraft occurs because many individuals, especially those with histories of trauma, neglect, or self-criticism, have developed defenses against experiencing emotional pain. For some clients, self-compassion is unfamiliar and may even feel threatening because it contrasts sharply with long-held patterns of self-judgment, self-blame, or avoidance. When a person begins to treat themselves with warmth and understanding, previously suppressed emotions such as shame, grief, anger, or fear can surface, sometimes in overwhelming ways. It is therefore essential that clinicians are appropriately equipped to manage backdraft effectively and safely, including by creating a safe therapeutic environment, validating experiences, and guiding the client through emotional regulation. Research suggests that trauma-related thoughts and emotions that emerge during meditations can undermine the effectiveness of treatment (Kirk et al., 2022). Backdraft may even lead to harmful long-term mental health effects, making it even more critical for researchers and clinicians to be mindful of these adverse reactions when working with self-compassion interventions. Unfortunately, there is currently no clear conceptual definition of backdraft and a scarcity of research on the backdraft experiences of participants for self-compassion interventions across populations (Cai et al., 2024).

Why Backdraft may be Particularly Relevant for Autistic People

Research indicates higher rates of trauma, abuse, bullying, and other adverse experiences that autistic individuals face across their lifespans than non-autistic individuals (Gibbs et al., 2022). A recent systematic review found that the occurrence of interpersonal violence reported by autistic adults is extremely high: 44%–62% for sexual violence, 40%–60% for physical violence, and 60%–70% for emotional abuse (Gibbs et al., 2024). Hence, many autistic clients enter therapy carrying significant trauma. Existing mental health treatments (including cognitive behavioral therapy) may not be well suited to many autistic clients due to reasons such as treatments not fit for purpose and due to miscommunication between clinicians and autistic clients (Camm-Crosbie et al., 2019; Maddox et al., 2019), highlighting the need for more appropriate strategies.

Therapies like CFT and MSC offer promising alternatives. Rather than focusing on analyzing the past, these approaches emphasize cultivating self-compassion, mindfulness, and emotion regulation skills in the present moment. The structured psychoeducation and practical exercises in CFT and MSC provide autistic clients with tangible and evidence-informed strategies to compassionately relate to their intense emotional pain, foster a kinder self-to-self relationship, and enhance emotion regulation. Indeed, a recent study by Cai et al. (2024) on a self-guided online self-compassion program (Aspect Self-compassion Program for Autistic Adults [ASPAA]) for autistic adults based on MSC and CFT found that after 5 weeks of completing the program, not only did self-reported self-compassion levels of autistic participants improve, but also emotion regulation abilities, mental health, and psychological well-being.

Due to the high level of past trauma experienced by many autistic adults, introducing self-compassion-based practices is likely to lead to experiencing backdraft. Cai et al. (2024) monitored backdraft experiences through weekly catchups with the 39 autistic participants over a 5-week period. For each new self-compassion practice introduced through the program for that week, participants were asked how they felt when they first tried the practice and how they felt in that moment (after doing the practice for a few days). If the practice brought up uncomfortable feelings or thoughts, then the participant was asked to stop the practice and wait until they tried the next practice in the next program module. Through this approach, Cai et al. found that over half of the autistic participants (54%) reported experiencing backdraft while completing ASPAA. Backdraft experiences included unpleasant emotions, self-critical thoughts, and physical discomfort. During the design phase of the study, the researchers tried to reduce the risk of harm to participants through several strategies, including excluding vulnerable individuals, maintaining weekly catchups with participants, having a clinically trained psychologist on hand to provide additional support, and providing participants with a list of support organizations. Even with these mitigants, some participants described their experiences as “painful,” “quite uncomfortable,” “confronting,” and “rather horrible” (Edwards et al., 2024).

Recommendations

Due to the substantial number of autistic adults experiencing backdraft when practicing self-compassion and the likely short-term and potentially long-term negative impacts associated with backdraft, we make the urgent call for (1) therapists to proactively address backdraft during compassion-based therapies when working with autistic clients and (2) researchers to study the lived experiences of backdraft, mechanisms of backdraft, and evidence-based strategies to address backdraft in autistic adults.

Clinical Recommendations

Good practice guidelines on how to adapt mental health talking therapies for autistic adults already exist (e.g., the National Autistic Society's Good Practice Guide for Mental Health Professionals, 2021), but no guidelines specifically address backdraft. As research on compassion-focused approaches grows, the development of evidence-based recommendations for managing backdraft in therapy could be an important step in supporting autistic clients. Drawing on existing good practice guidelines, as well as our own research and clinical experience with autistic people, we outline several preliminary recommendations for addressing backdraft in therapy for autistic adults (Table 1). While we consider these recommendations sensible and aligned with good practice guidelines and lived experiences, further research is needed both on the effectiveness of these recommendations and on backdraft in general.

Table 1.
Preliminary Recommendations for Addressing Backdraft in Therapy for Autistic Adults

Recommendations/strategies

Psychoeducation
Explain backdraft and prepare the client in simple, accessible language.

Reframe backdraft as growth and healing. Explain that the discomfort is temporary and indicates that they are beginning to soften and challenge old patterns of self-criticism and shame. It is important to encourage clients to hold a long-term view of the process. Backdraft may be difficult, but it is also an opportunity to confront and heal old wounds.

To reduce how scary the prospect of backdraft might be, introduce it along with more positive concepts such as the development of “courage” and “trust.” Indeed, a lot of courage is required by the client to trust the therapeutic process, especially when backdraft feels overwhelming. Being vulnerable is a courageous act—it requires choosing growth over comfort.

Provide visual aids that outline the concept of backdraft. Consider creating or using backdraft diagrams. This might include a flowchart showing how self-compassion can lead to discomfort before leading to healing. Handouts can be useful as clients can take these home to reflect on between sessions.

Examine the issue of overmedicalization of mental health conditions and traumatic reactions, highlighting how they have been framed as “dysfunctions” rather than naturally evolved “functional” reactions that need caring, support, and guidance (Gilbert, 2022). Explain to clients how this can seriously undermine the validation of people's efforts to use experiences for growth.

Normalization
Acknowledge and validate the experience of backdraft and frame it as a normal and common part of the healing process.

Emphasize its commonality, particularly in autistic people, and depending on the client, highlight its commonality in similar individuals (e.g., individuals with a history of trauma, shame, or self-criticism, as relevant).

Without violating confidentiality, share anonymized or generalized examples of how other clients have experienced and worked through backdraft. Hearing about others’ experiences can help normalize the process.

Structure of practice
Consider the pace of practices—begin with smaller, more manageable exercises before moving on to more in-depth practices.

Consider the order of practices—cover soothing and self-care techniques early on to build resiliency skills before encroaching on more difficult territory.

Develop competencies that support working with trauma memories early on in therapy.

Ensure regular check-ins to see how the client is progressing with their self-compassion practices and backdraft experiences.

Incorporate regular reflection points. Reflection exercises can allow the client to process backdraft experiences. It can be useful to revisit and discuss previous backdraft experiences in later therapy sessions and identify any patterns around when these occur.

Focus on safety
Reassure clients that they are not alone in facing backdraft and that you will work together through the challenging emotions.

Reassure clients that they are in control of the pace of the therapy.

Regularly assess how the client is responding and adjust interventions as necessary. If backdraft persists regularly over many sessions, it may be necessary to spend more time on emotional regulation or shift focus to other therapeutic modalities.

If backdraft becomes overwhelming or retraumatizing, take a step back from compassion work and focus on stabilization techniques.

Reasonable adjustments (some of which are recommended in compassion-focused therapy, Oxford University Press, by James Acland and Debbie Spain, 2022, and added to here with our own recommendations)
Incorporate reasonable adjustments in self-soothing activities (e.g., to the temperature, sound, light). This can reduce sensory distress, which may reduce the risk of backdraft occurring in the first place, and allow for better coping generally within the session.

Use time-limited special interests as a way to create a sense of safety in the therapeutic space.

Encourage clients to draw different emotions that arise to help externalize these.

Allow more time for behavioral experimentation.

Use sensorily adapted mindfulness techniques to make it easier to handle backdraft.

Provide concrete examples of self-compassion that are relevant to the client's experiences and context. Concrete examples can make more abstract concepts more accessible, especially for autistic people who may process information literally.

Focus on autistic strengths and abilities and incorporate these into the therapy process. This can foster a sense of confidence and courage when overcoming backdraft.

Support the client in accepting their own way of interacting with and processing emotions, rather than conforming to standard approaches. A personalized approach can make it easier for autistic clients to address backdraft without feeling pressured to conform to standard emotional responses.

Allow the client to choose between different exercises or methods to find what works best for them. This can be empowering and give clients a sense of control in managing their emotions in therapy.

Carefully manage therapy endings—plan for gradual tapering of sessions. For example, compile a diagrammatic therapy blueprint or video/audio recording of key points to support the client after therapy concludes. Focus some aspects of these materials on how backdraft was managed during therapy, when it was done well, and how this learning can be used beyond therapy.

Recommendations for Addressing Trauma

In the context of CFT, Professor Paul Gilbert (2022) refers to fears, blocks, and resistances (FBRs) as emotional and psychological barriers that arise from past experiences, trauma, or learned behaviors that inhibit the development of compassion toward oneself and others. For autistic clients, it is particularly important that FBRs are approached with sensitivity, as the occurrence of backdraft can reinforce FBRs, leading to a cycle that hinders therapeutic progress. We strongly recommend that therapists working with autistic clients be adept at preventing clients from becoming overwhelmed during sessions and use trauma-informed therapeutic approaches. Without adequate therapeutic attunement and grounding, revisiting traumatic memories can increase the likelihood of autistic clients becoming emotionally flooded or dysregulated. Autistic clients may also be more vulnerable to shame-based difficulties and experience an intense “then vs now” disconnection (Galvin, Howes, et al., 2024), vividly re-experiencing past traumas in the present moment and becoming overwhelmed by resurfacing emotions, memories, and physiological responses without sufficient coping strategies. It is now widely accepted to provide phase-based treatments for clients with complex trauma (Lee, 2022), focusing first on building resources, safety, and stability before addressing trauma stories.

Trauma-sensitive approaches may be particularly useful for therapeutically addressing backdraft for autistic clients. Van der Kolk (2014, p. 97) poignantly describes traumatized people as feeling “unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort. Their bodies are constantly bombarded by visceral warning signs, and, in an attempt to control these processes, they often become expert at ignoring their gut feelings and in numbing awareness of what is played out inside. They learn to hide from their selves.” Asking traumatized autistic clients to reconnect with their bodies through self-compassion practices that use mindfulness techniques (e.g., compassionate body scan and mindfulness meditations) can activate unpleasant and distressing sensations. Incorporating techniques from trauma-sensitive mindfulness practices may be helpful in addressing trauma-related symptoms (Cai et al., 2024). These techniques include training individuals to cope with these symptoms, gradually increasing people's capacity to direct and maintain voluntary attention, and offering an approach that empowers individuals to make personalized adjustments to suit their tolerance levels (Wästlund et al., 2024).

One well-established therapeutic technique for reducing the intensity of trauma responses that may be used alongside compassion-based therapies for autistic adults is eye movement desensitization and reprocessing (EMDR; Shapiro, 1989). EMDR is a protocolized treatment designed to alleviate the distress associated with traumatic memories. Developed by Francine Shapiro in the late 1980s, EMDR involves the client recalling distressing experiences while simultaneously engaging in bilateral stimulation, such as guided eye movements, tapping, or auditory tones. The theory behind EMDR suggests that this dual attention to the traumatic memory and the external stimulus allows the brain to process and reframe the memory in a less distressing way. Over a series of sessions, EMDR helps clients reduce the emotional impact of trauma, leading to improved psychological functioning and a decrease in symptoms related to post-traumatic stress disorder (PTSD), anxiety, and other mental health conditions. EMDR has been widely researched, with several meta-analyses showing it offers similar or higher efficacy for supporting people with PTSD compared to pharmacological or other psychological interventions (Bisson et al., 2007, 2013; Chen et al., 2014). Despite the initial skepticism from the scientific community (Herbert et al., 2000; McNally, 2013), EMDR has since been recognized as an effective treatment for trauma by various global and country-specific (e.g., the United States and United Kingdom) health organizations, including the World Health Organization (WHO, 2013), the American Psychological Association (APA, 2017), and the National Institute for Clinical Excellence (NICE; Ost & Easton, 2006). While other Western countries like Australia have recently started to see its value in reducing posttraumatic stress symptoms (APS, 2019).

Several models of EMDR have been proposed. Landin-Romero et al. (2018) conducted a systematic review to understand the mechanisms of action of EMDR. They identified 87 studies and classified them as psychological, psychophysiological, or neurobiological models. The authors concluded that there is reasonable empirical support for the working memory hypothesis and physiological changes associated with successful therapy. The working memory model suggests that EMDR works by overloading the working memory, leading to the desensitization of traumatic memories (see a review of this model by Wadji et al., 2022). According to this model, when a person recalls a traumatic memory while simultaneously engaging in a secondary task (bilateral stimulation like eye movement), the demands on working memory are increased. Since working memory has limited capacity, the simultaneous task of maintaining the traumatic memory while performing the bilateral stimulation reduces the vividness and emotional intensity of the memory. Over time, this process helps the individual reprocess the memory, making it less distressing and easier to manage. The physiological changes from EMDR include decreases in heart rate and galvanic skin response (Wilson et al., 1996), suggesting increased parasympathetic contribution to autonomic activity (Elofsson et al., 2008). More recently, neuroimaging studies have provided empirical evidence for brain changes, including changes in interhemispheric connectivity (e.g., Keller et al., 2014; Yaggie et al., 2015), increased activity in anterior cingulate gyrus and the left frontal lobe (Levin et al., 1999), decreased activation in occipital, left parietal and posterior frontal lobes (Lansing et al., 2005), and metabolic increases in the left inferior frontal gyrus and bilateral dorsolateral prefrontal cortex (Lansing et al., 2005; Oh & Choi, 2007). There is also evidence for brain functional changes (Buckner et al., 2008; Landin-Romero et al., 2013; Ohtani et al., 2009).

There is steadily growing research on EMDR for autistic children and adults. Earlier case reports suggest EMDR is feasible and promising as a treatment for PTSD and trauma (Ipci et al., 2017; Kosatka & Ona, 2014; Mevissen et al., 2011), even for autistic adults with co-occurring intellectual disabilities (Barol & Seubert, 2010; Mevissen et al., 2011). Since the publication of this research, a couple of more recent studies have examined the efficacy of EMDR for autistic adolescents and adults. Lobregt-van Buuren et al. (2019) conducted a study using non-randomized add-on design on the feasibility and efficacy of EMDR for PTSD symptoms in autistic adults with a history of adverse events and found significant reductions in post-traumatic stress symptoms, psychological distress, and autistic traits. These results were maintained at follow-up. The researchers noted the remarkable finding of the significant improvements in social motivation and communication (albeit with a small effect size). They proposed one possible explanation might be the clinical manifestations of autistic traits diminishes when people experience reduced trauma-related stress and psychological distress, such as somatization, depression, and obsessive–compulsive symptoms. Consequently, it is plausible that psychosocial factors, including exposure to adverse events and trauma, amplify the expression of core autistic traits. Another potential explanation suggested by the researchers for the reduction in autistic traits observed in this study is the phenomenon of diagnostic overshadowing, where PTSD symptoms are mistaken for autistic traits. For instance, hyperarousal resulting from trauma might be misinterpreted as sensory hyper-reactivity, a common autistic feature. Similarly, trauma-related avoidance of social situations could be confused with difficulties in social communication. Hence, some PTSD symptoms may be masked by autism, so what were previously thought to be autistic traits may have been PTSD symptoms that reduced following EMDR. Interestingly, this finding of reduced autistic traits following EMDR was not found in an uncontrolled study by Leuning et al. (2023) of autistic adolescents. They did find significant reductions in self-reported stress and improvement in global clinical functioning, as rated by an independent child psychiatrist, between baseline and 3-month post-treatment follow-up. Overall, there is preliminary evidence for EMDR reducing trauma-related symptoms and perceived stress in autistic individuals.

Research Recommendations

Several research directions could help clinicians and researchers better understand the experience of backdraft in autistic populations and inform effective support options. Backdraft is not a simple, one-dimensional experience. It emerges from a complex interplay of cognitive, emotional, and physiological factors. Therefore, examining the mechanisms that lead to backdraft through a biopsychosocial lens is essential. One priority is that RCTs of self-compassion interventions should track and document the experiences and therapeutic management of backdraft. Longitudinal studies could observe how backdraft evolves throughout the therapeutic process, tracking its short- and long-term impacts on well-being and therapeutic outcomes. Exploring how specific autistic traits influence the frequency and intensity of backdraft could highlight potential vulnerabilities or resilience factors. Research into coping strategies (e.g., grounding techniques, sensory regulation tools) would provide valuable insights into their effectiveness in mitigating backdraft for autistic individuals and evaluate their implementation in clinical practice. Additionally, exploring the interaction between backdraft and FBRs could offer a deeper understanding of how backdraft may reinforce these barriers.

Collecting subjective experiences of backdraft through interviews or case studies would provide essential lived-experience perspectives, similar to the preliminary efforts of Cai et al. (2024). Autistic voices are vital to gather firsthand accounts of backdraft that illustrate how autistic individuals navigate these experiences. Subjective narratives can provide insight into what backdraft feels like on a personal level and how it intersects with the broader autistic experience. Finally, it is also important to evaluate clinician knowledge and training on managing backdraft in autistic clients. An assessment of current knowledge of therapists working with autistic clients, and strategies they use to manage backdraft, could be informative. This could reveal gaps in clinician understanding and inform the development of effective training programs. Across all these research avenues, we recommend participatory and co-designed studies to ensure the autistic experience is central to our understanding of backdraft and how it is managed during therapy.

Conclusion

Emerging research shows the transformative potential of compassion in supporting autistic people with mental health challenges. As the field moves toward intervention work, it is important for researchers to investigate the unique experiences of backdraft in autistic populations and for clinicians to adopt trauma-sensitive practices to mitigate its effects. This perspective article has explored why backdraft is particularly relevant for autistic populations and provided recommendations for addressing it in both research and clinical settings. We encourage further investigation into the mechanisms behind backdraft and its effects on autistic individuals, paving the way for evidence-based strategies that enhance clinical support.

	Recommendations/strategies
Psychoeducation	Explain backdraft and prepare the client in simple, accessible language. Reframe backdraft as growth and healing. Explain that the discomfort is temporary and indicates that they are beginning to soften and challenge old patterns of self-criticism and shame. It is important to encourage clients to hold a long-term view of the process. Backdraft may be difficult, but it is also an opportunity to confront and heal old wounds. To reduce how scary the prospect of backdraft might be, introduce it along with more positive concepts such as the development of “courage” and “trust.” Indeed, a lot of courage is required by the client to trust the therapeutic process, especially when backdraft feels overwhelming. Being vulnerable is a courageous act—it requires choosing growth over comfort. Provide visual aids that outline the concept of backdraft. Consider creating or using backdraft diagrams. This might include a flowchart showing how self-compassion can lead to discomfort before leading to healing. Handouts can be useful as clients can take these home to reflect on between sessions. Examine the issue of overmedicalization of mental health conditions and traumatic reactions, highlighting how they have been framed as “dysfunctions” rather than naturally evolved “functional” reactions that need caring, support, and guidance (Gilbert, 2022). Explain to clients how this can seriously undermine the validation of people's efforts to use experiences for growth.
Normalization	Acknowledge and validate the experience of backdraft and frame it as a normal and common part of the healing process. Emphasize its commonality, particularly in autistic people, and depending on the client, highlight its commonality in similar individuals (e.g., individuals with a history of trauma, shame, or self-criticism, as relevant). Without violating confidentiality, share anonymized or generalized examples of how other clients have experienced and worked through backdraft. Hearing about others’ experiences can help normalize the process.
Structure of practice	Consider the pace of practices—begin with smaller, more manageable exercises before moving on to more in-depth practices. Consider the order of practices—cover soothing and self-care techniques early on to build resiliency skills before encroaching on more difficult territory. Develop competencies that support working with trauma memories early on in therapy. Ensure regular check-ins to see how the client is progressing with their self-compassion practices and backdraft experiences. Incorporate regular reflection points. Reflection exercises can allow the client to process backdraft experiences. It can be useful to revisit and discuss previous backdraft experiences in later therapy sessions and identify any patterns around when these occur.
Focus on safety	Reassure clients that they are not alone in facing backdraft and that you will work together through the challenging emotions. Reassure clients that they are in control of the pace of the therapy. Regularly assess how the client is responding and adjust interventions as necessary. If backdraft persists regularly over many sessions, it may be necessary to spend more time on emotional regulation or shift focus to other therapeutic modalities. If backdraft becomes overwhelming or retraumatizing, take a step back from compassion work and focus on stabilization techniques.
Reasonable adjustments (some of which are recommended in compassion-focused therapy, Oxford University Press, by James Acland and Debbie Spain, 2022, and added to here with our own recommendations)	Incorporate reasonable adjustments in self-soothing activities (e.g., to the temperature, sound, light). This can reduce sensory distress, which may reduce the risk of backdraft occurring in the first place, and allow for better coping generally within the session. Use time-limited special interests as a way to create a sense of safety in the therapeutic space. Encourage clients to draw different emotions that arise to help externalize these. Allow more time for behavioral experimentation. Use sensorily adapted mindfulness techniques to make it easier to handle backdraft. Provide concrete examples of self-compassion that are relevant to the client's experiences and context. Concrete examples can make more abstract concepts more accessible, especially for autistic people who may process information literally. Focus on autistic strengths and abilities and incorporate these into the therapy process. This can foster a sense of confidence and courage when overcoming backdraft. Support the client in accepting their own way of interacting with and processing emotions, rather than conforming to standard approaches. A personalized approach can make it easier for autistic clients to address backdraft without feeling pressured to conform to standard emotional responses. Allow the client to choose between different exercises or methods to find what works best for them. This can be empowering and give clients a sense of control in managing their emotions in therapy. Carefully manage therapy endings—plan for gradual tapering of sessions. For example, compile a diagrammatic therapy blueprint or video/audio recording of key points to support the client after therapy concludes. Focus some aspects of these materials on how backdraft was managed during therapy, when it was done well, and how this learning can be used beyond therapy.

Footnotes

ORCID iDs

Ru Ying Cai

John Galvin

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

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Self-Compassion isn’t Always Easy: Helping Autistic Adults Navigate Difficult Responses to Self-Compassion Practices

Abstract

Keywords

Self-Compassion

Backdraft and its Purpose in Healing from Past Hurts and Trauma

Why Backdraft may be Particularly Relevant for Autistic People

Recommendations

Clinical Recommendations

Recommendations for Addressing Trauma

Research Recommendations

Conclusion

Footnotes

ORCID iDs

Funding

Conflicting Interests

References