‘They've Almost Got,Like,a Checklist to Work Down’: On the Lived Experiences of Autistic Adults Who Have Received a Structured Therapy Service for Depression and/or Anxiety Disorders

Abstract

Autistic adults experience higher rates of common mental health conditions than non-autistic adults and report greater difficulties accessing mental health services. In England, psychological therapy for anxiety and depression is primarily delivered through NHS Talking Therapies for Anxiety and Depression (TTad), but little is yet known about autistic adults’ experiences of these services. Using Interpretative Phenomenological Analysis, we conducted in-depth online interviews with five formally diagnosed autistic adults, all in their twenties at time of interview, who had received TTad therapy for depression and/or anxiety conditions. Four superordinate themes emerged: Pre-Therapeutic Context, highlighting how participants’ autism diagnoses had been transformative, and how diagnosis had shaped their therapy experiences; Therapeutic Relationship, emphasising the importance of a therapist's flexibility and understanding of autism, and the damage that could be done by them minimising the relevance of participants’ autism itself; Rigidity and Quantification, addressing challenges with standardised approaches and outcome measures; and Training and Adaptation, identifying how therapists often developed more effective approaches over time, to demonstrably positive therapeutic ends. Findings suggest that TTad services (and analogous international programmes) may require greater flexibility in delivery, enhanced autism awareness among practitioners, and potentially extended treatment timeframes for autistic clients.

Lay Abstract

The experiences of autistic adults who received talking therapy for depression and anxiety disorders

We are a group of academic researchers, psychological therapists, and autistic individuals, with some of us being more than one of these things. We investigated how autistic adults experience talking therapy services in England, specifically focusing on their experiences with depression and anxiety treatment. We interviewed five autistic adults in their twenties who had received therapy through the NHS Talking Therapies for Anxiety and Depression (TTad) service. Our findings revealed that participants’ journeys to autism diagnosis significantly shaped how they engaged with therapy, and that therapists should not underestimate the difficulties of this journey. Participants reported that their therapists sometimes seemed unprepared to understand how autism impacts mental health. They also found the rigid structure of therapy and progress measurement methods challenging. However, therapy became more helpful when therapists demonstrated flexibility and willingness to adapt their approach. The participants emphasised the importance of autistic people continuing to access these services, as few alternatives were available to them when experiencing depression or anxiety. We recommend training for psychological therapists to better understand the specific needs of autistic people and how to adapt therapy approaches to make them more effective.

Keywords

depression anxiety interventions – psychosocial/behavioural health services mental health neurodiversity qualitative research

Introduction

Autistic adults are more likely to experience common mental health conditions, such as depression or anxiety conditions, than non-autistic adults (Miller et al., 2025; O'Nions et al., 2024; Underwood et al., 2023). Understanding how these conditions interact with the personal and interpersonal impacts of autism itself is complex, but the consequent impact on quality of life, and the effectiveness of evidence-based mental health interventions can be considerable (Camus et al., 2024; Menezes et al., 2022; Nimmo-Smith et al., 2020; Wilson & Gullon-Scott, 2024a, 2024b). For example, factors including intolerance of uncertainty (i.e. difficulties managing uncertain and unpredictable events), challenges of sensory processing, and experiences of isolation and stigmatisation are associated with experiences of anxiety (Moore et al., 2022; South & Rodgers, 2017). Autistic adults are more likely to need mental health services than those who are not autistic but report greater difficulties in accessing these services than the non-autistic population, with lower satisfaction with outcomes (Adams & Young, 2021; Hirvikoski et al., 2016; Mason et al., 2019)

In response, research has increasingly focused on the adjustments needed within healthcare for autistic people, including understanding the client's communication style, adapting sensory environments and improving clinicians’ understanding of autism itself (Brice et al., 2021; Doherty et al., 2023). Specific psychological therapies for autistic people with co-occurring depression and anxiety have also been explored for feasibility, though no firm evidence-base has yet been established (Rodgers et al., 2024; Russell et al., 2020)

In England, psychological therapy for adults with an anxiety disorder and/or depression is chiefly provided in the NHS Talking Therapies for Anxiety and Depression (NHS TTad) system, formerly known as Improving Access to Psychological Therapies (IAPT). This service uses a stepped-care model in which a low-intensity treatment is offered to most people, from a registered Psychological Wellbeing Practitioner (PWP), typically qualified via an undergraduate (level 6) programme accredited by the British Psychological Society (BPS), or a BPS-accredited equivalent. If they do not recover to an agreed level following this treatment, they can then be ‘stepped up’ to a high-intensity intervention, delivered by a registered High Intensity Therapist (HIT). In the UK, qualification for HIT status requires a postgraduate diploma (level 7) or higher in a specific psychotherapeutic area, accredited by the BABCP (British Association for Behavioural & Cognitive Psychotherapies). Timeframes for therapy in either step are contingent upon determined needs and service availability, although it is expected that the time spent in the first will typically be in the range of six the twelve weeks. Within this period, a decision will be jointly made regarding the ultimate need to step-up or discharge. Time spent in the second step, meanwhile, is entirely contingent upon needs. A fuller account of this model, including detailed PWP and HIT competencies, is provided in the NHS Talking Therapies for Anxiety and Depression Manual v7 (National Collaborating Centre for Mental Health, 2024)

A small body of research has to date considered autistic people's experiences of psychological therapies (Jubenville-Wood et al., 2023; Mazurek et al., 2023; O'Brien et al., 2024; Pappagianopoulos et al., 2025). These studies suggest that the positive experience of therapy is contingent on a therapist's understanding of autism, and their ability to adapt therapeutic strategies to an autistic person's needs. However, there remains limited evidence addressing how autistic people understand and contextualise their therapeutic experiences.

The primary aim of this study is to explore the detailed lived experiences of autistic adults with depression and/or anxiety conditions who have accessed the NHS TTad system. It is hoped that findings will inform such therapy and services for autistic people and guide best practice in the adaptation of common therapeutic techniques for such clients.

Methods

In this paper, we report qualitative data collected through extended online interviews during the first quarter of 2023. We adopted Interpretative Phenomenological Analysis (IPA) as our primary methodology (Howard et al., 2019; Nimbley et al., 2023). We deemed this to be the most appropriate approach given the focus of IPA upon participant experience and idiographic sense-making (MacLeod, 2019). Full ethical approval for the study was received from the institution of the first author (ref: 22/09), and we collected and handled all data in strict accordance with the terms of this approval.

Participants

In response to recruitment posts on a range of social media platforms, five formally diagnosed autistic adults with experience of NHS TTad services consented to participate. The sample size is consistent with IPA recommendations, given the highly detailed analytic approach (Miller et al., 2019). All participants were in early adulthood at the time of interview, and all had received their autism diagnoses relatively recently (within the previous six years). All participants had more than one referral to TTad with the first referral made by GPs and subsequent contacts being largely through self-referral. Given the potential sensitivity of the topic and an anticipated concern among prospective participants around identity protection, ethical approval conditions required that no further individual demographic details are reported in any published work outside of that which participants actively chose to reveal during their interviews.

Procedure

The first author prepared a semi-structured interview schedule, which the full research team reviewed and amended. The final schedule is available as a supplementary file. The second author sent the interview schedule to all participants in advance of their interviews, which she subsequently conducted using Microsoft Teams at a time of the participants’ choosing. At each interview, participants were asked to identify any distractions (e.g. background sounds, lighting) so that these could be addressed before the interview and participants were offered regular breaks. The second author then transcribed the interviews in full, and anything that required further clarification was checked with the participants to enhance credibility in interpretation.

Data Analysis

We analysed the data in line with the flexible IPA guidance described by Biggerstaff and Thompson (2008). The second author undertook the initial encounter with the text, and then the first and second authors discussed and identified preliminary themes. The first author grouped these themes into clusters and developed a broader scheme of thematic relationships. The full research team then reviewed and discussed these with reference to the original data until we reached a mutually agreeable interpretation. This latter phase ultimately amounted to a re-naming (and simplification) of the superordinate themes, so that they might be relevant to therapists and autistic service users alike.

Community Involvement Statement

Two of the authors of this article are autistic, three are working psychological therapists, and all are experienced qualitative researchers. These positions, in collaboration, shaped the design and execution of the research at all levels. The interview schedule was also reviewed by an autistic advocate with experience of NHS TTad services, who did not propose any necessary changes.

Results

Analysis of the interviews with autistic people who had accessed NHS TTad yielded four superordinate themes:

Pre-Therapeutic Context

Therapeutic Relationship

Rigidity and Quantification

Training and Adaptation

A thematic map, showing how superordinate themes were derived from branching subordinate themes, is shown in Figure 1.

Figure 1.

Thematic Map of Interview Data.

The analysis is described below, supported by direct data where this further illustrates the themes.

Pre-therapeutic Context

Pathway to Autism Diagnosis

The periods between referral to a diagnostic service and formal diagnosis were variable and often involved significant waiting periods (over two years in one case). For all participants, the path to an autism diagnosis began with referrals to services or practitioners for other mental health or behavioural issues. For example:

P1: I had some really bad trouble that led to me ending up in hospital and having to speak with the crisis team and during like the conversation with the crisis team, I felt like they kept trying to force me into a box that I didn't feel quite fit. So afterwards I decided to do some of my own research about like how I've been feeling, what was going on inside my head… I started trying to like figure out when it started, things like that and the one thing that kept popping up was autism… So I got in touch with my doctors and they referred me to the adult autism assessment team … and I was on the waiting list for two years-ish… I had a couple of appointments with them and then they diagnosed me officially [four months later].

All participants identified key ‘gatekeepers’ who had facilitated or impeded their autism referral or assessment. These included school and university counsellors, GPs, support workers and, in one case, TTad therapists. While most were seen to have ‘done their best’, there was a concern that the less helpful gatekeepers simply did not know enough about autism to recognise it as a possible consideration.

P2: [T]hey said that I was being referred [to TTad] for CBT [Cognitive Behaviour Therapy]. However, I know that normally CBT only gets six weeks, and I worked with my therapist for 12 months … [and] … really she really went into the deep depths of trying to understand what my triggers were. But again, she didn't think I was autistic. She just thought that I had a lot of inbuilt stress or traumas.

This inferred lack of knowledge about autism among gatekeepers had also led to some unfortunate therapeutic choices. P4 was, for example, referred to group CBT by university mental health services (for anxiety) which was not adapted to meet the needs of autistic people, despite already being under assessment for autism at the time, and found it to be an unpleasant and isolating experience.

P4: I went to group CBT and there was lots of people who had anxiety [and] I had anxiety, but it made me feel bad because I felt like I was just way more extreme than everyone else. I felt a bit embarrassed. Like they were talking about like having panic attacks in class and stuff but for me it was like way more extreme, and I just felt a bit embarrassed. I thought it would be like useful to see how other people dealt with things, but made me feel like ‘Ohh, it must be something really wrong with me compared to what everyone else is going through’.

Accounts were also given of how families and friends had, often in a well-meaning way, told participants that they ‘couldn’t be’ autistic due to effective masking:

P4: I'd been chatting with [friends], it all seemed a little bit unclear because obviously I was much older and I was a woman and it didn't maybe… I think a lot of people were a bit like ‘OK, well, someone's told you to get an assessment, but I don't really know why – doesn't really make sense … you wouldn't be at university if you had autism’ sort of thing.

P5: My mum is, or was, a social worker and so whenever I brought the idea of, ‘I might be autistic’ – ‘No, no, you're not’. Slap it down. Slap it down, slap it down.

Benefits of Autism Diagnosis

All participants, irrespective of the degree to which they had expected their autism diagnosis, or length of time over which they had been expecting it, ultimately found its receipt to be positive on multiple levels.

P3: I wouldn't change a thing about being autistic. Some days I would. Some days I honestly would. But then when I got diagnosed, it only clicked like six months later. Like, this is what you need.

Firstly, the diagnostic process and participants’ own research were described as having enabled them to make sense of their own biography in a new light. They were able to reclaim their narrative as ‘relatively normal’ for an undiagnosed neurodivergent individual, and to understand their mental health conditions in this context.

P1: [After diagnosis] I did a lot of my own research on stuff … mostly on social media. I followed a lot of creators who were also diagnosed autistic and female, so then I could figure out their stories and how it connected with mine.

The formal diagnosis was seen to have helped greatly with social and physical contexts, particularly home and work, where adjustments were no longer considered as due to their personalities, but rather a reasonable accommodation for an autistic person.

P1: …having my family like understand, you know, autism and how it affects me. Having that sort of understanding that wasn't really there before because it was just sort of like ‘Ah it's just [P1], she's just got some quirks’. But then they would like, keep trying to still force me to be [makes air quotes] normal. Whereas now I feel like I can sit them down and explain ‘Hey, look, I really physically cannot do that. It's not the case that I won't… I really cannot do that’.

This overlaps a final issue in the participants’ accounts of this matter, which was that a formal diagnosis functioned as a passport into stronger informal and formal support systems for autism itself and other attendant issues:

P1: About a week after I got diagnosed, everything shut down with COVID but after everything started reopening, I started signing up for like support groups … on social media. And I've definitely got a lot more of a support structure in place to help when things get a bit difficult… I've made a lot of friends through the support groups that I signed up with.

P3: Because of my epilepsy and I need carers – I got more help with care when I was diagnosed with autism even though my epilepsy is uncontrolled.

TTad Referral

Participants reported several TTad referrals. However, all had been referred at least once after being diagnosed. The participants were referred to TTad with depression for all, and co-occurring anxiety for most. All observed that TTad services had only been offered when they were experiencing more significant distress in relation to co-occurring mental health conditions, with significant impacts on their family, social and/or working lives.

P2: [T]he screening woman that I spoke with, who picked up my referral, asked me questions that weren't to script… The question is always ‘Have you thought about killing yourself in the last two weeks’ or I can't remember the exact wording, but it's very bluntly. ‘Have you thought about this?’ But she asked me ‘Have you got a plan to help you, if you want to kill yourself’ and I went ‘Well, what do you mean by that?’ She was like, ‘Well, if you got a will, have you got arrangements put in place that if you die everything will be arranged?' ‘Oh god, yeah, I've had that for years! I if I clocked it today, no one would be left in the lurch. Are all of my financial assets my dog, my house? That is all pre prepared and planned for’ and she went ‘Yeah, that that is a sign that you're probably trying to kill yourself’.

At their first referral post-diagnosis of autism, participants noted that autism itself was not a key consideration within Talking Therapies:

P5: [T]hey just turned around and said, ‘Well, we can't help with that [autism] because we're not trained in that, and the only thing I can help you with is anxiety and depression’.

Given the already described degree to which an autism diagnosis had helped them contextualise and make sense of their own mental health, this was found to be a point of confusion and highlighted potential challenges in different expectations of autistic people and clinicians in NHS TTad.

Therapeutic Relationship

Autism Salience

Following directly from the observations above relating to referral/admission into TTad services, participants highlighted how during psychological therapy, the salience of autism in their lives and mental health seemed to go largely unrecognised – therefore largely unaccommodated by their therapists, at least at first. This was evident in three related elements. Firstly, autism was sometimes not picked up as relevant to the therapeutic context, which meant that the participants felt it was functionally ignored. Secondly, autism was acknowledged, but not as relevant to the mental health conditions for which the participant was receiving therapy. Finally, a relationship between mental health conditions and autism was acknowledged, but the therapist seemed to have limited knowledge/training around what that might be or how to handle the matter in practice.

P5: The person that I was working with was young and she was blank faced, confused, most of the time. She started off with ‘We don’t work with autistic people’.

Tricky Therapeutic Interaction

Following from the previous subtheme, participants were clear that their therapists seemed not only under-trained about autism and autistic people's experience of mental health but also about how autism might impact upon the interpersonal, therapeutic domain itself. Participants viewed their therapists as struggling to adapt to their specific needs from the outset and identified a range of less helpful actions, such as assuming shared understandings, using abstractions rather than concrete examples, or using ‘set’ and often inflexible questions with a pace that was difficult to follow.

P1: [T]here's a lot of times where I've gone in and they've just mentioned something as if I'm supposed to know what it was and just understand it. So [I needed] an explanation of how something worked or what they meant by certain things that they've said… Sometimes it's a mixture of medical jargon and I've just not understood what it was, and sometimes it was a case of where they’ve described something, and I've not understood.

P2: [T]he initial appointments were hard but that's because she was working on the script, because that's what she's told and trained to do, and that's what they get assessed against of ‘Did you work through this, this, this?’… Me, being me, I was very open about ‘So why are you asking me these questions in this order? Because they don't make sense!’ … the script isn't made for how my brain works.

However, the therapists were not seen as inherently ‘to blame’ for these problems. Rather, these issues were universally viewed as a service challenge, in terms of a lack of training and inflexible treatment offers. Some participants voiced active sympathy for therapists who were clearly trying their best. This did little to generate confidence in the therapy itself, particularly where participants felt they needed to educate their therapist (rather than it being viewed as a collaborative approach).

P4: A lot of times it would be like maybe the therapist has had, like, one session on autism and now they have a lot of questions, so then they're asking me for things or saying like so is this how you say it? Or ‘So this would be a special interest, would it be?’ and it just felt a little bit … strange.

However, all therapists were ultimately seen to continually strive to adapt, often successfully over time, and were consequently well-liked by the participants; this is discussed in more detail later in this analysis.

Positive Interactional Latencies

Participants voiced frequent scepticism regarding the efficacy of much of the therapy they received. However, all were positive about (a) their therapists (ultimately), and (b) the provision of a ‘safe space’ in which to talk about their mental health. This was considered as better than nothing at all, which is broadly what they would have received in the absence of TTad.

P4: [T]he person I got, she was very nice and sometimes with these things like which you maybe don't get as much of in the NHS, it's about like if you get on with the person, sometimes just a person level and I felt like she was … I really liked her and thought like ‘Ah, I'm really lucky’.

When TTad therapists were able to offer flexibility about how they delivered treatment, the sessions were described as providing an opportunity to articulate everyday challenges and talk-through difficult events.

P2: [The therapist] just enabled the conversation to go wherever my brain was going at the time, so it meant that I was actually much more engaged with what we were talking about because I could just go with this … we went wherever the conversation ended up. But then we talked about lots within the 45 minute appointments.

Rigidity and Quantification

Outcome Measuring

One particularly challenging aspect of participant experience in TTad related to the use of routine outcome measures. Some of the participants described a struggle to quantify their feelings:

P1: And it was basically a piece of paper with a bunch of different questions with on a scale… Do you feel depressed? Do you feel anxious? Have you had suicidal thoughts? Stuff like that. And then they have, like, scores based on those answers, but the problem is I really struggle to quantitate my feelings, so I've never really known what to put on those answers.

P5: I ended up just putting what I thought they were expecting me to put … because I felt like that was just easier. And I knew what they wanted me to put because I could remember what I put the week before, and I could remember what I put the week before that. And then I would just think, alright, so this week I am like 0.5 points better, so I'll put [motions filling in] that there and I'll put this there and I'll put that there.

While this illustrates the problems of these instruments in practice, some participants were more transparently concerned about the potential impacts on their place within the service if they were seen to improve too much/too little. Consequently, the same participant attempted to manipulate scores to represent sufficient improvement to remain with their therapist, who was well-liked.

P4: I want to [show] it was useful, but it was not … it felt like probably … the bare minimum that I needed… I think I wanted to be able to keep putting that I was getting better because I was maybe worried. I was probably worried … they would do what they did last time and stop [the therapy] again because I was too sick or something.

Conversely, another purposely inflated their progress scores in order to be discharged, after deciding that the therapy with which they were being provided was ineffective.

P1: I was discharged early because I kind of fudged the questionnaire numbers … and basically, because I felt like the CBT wasn't even doing anything, I just gave them the answers that they were looking for rather than what I was actually feeling.

Over-Structured Encounters and Therapy

Following from the above, a highly structured therapy approach was routinely criticised by participants as not sufficiently autism-informed and was often perceived as inappropriate and alienating.

P4: It was always, you know, them following a book or script or something … they never told me once why [CBT] would help.

All participants who could name the therapies they had received had undergone at least one programme of CBT, and they had not found it helped them in the way it was supposed to.

P3: I would go every 2 week and always have to fill out a form on my feelings, it was a 30-minute session and I just got handed leaflets all the time.

Participants did not always find it easy to explain why CBT did not make sense to them in this respect, but typically problems were rooted in a rigid and scripted approach.

P1: [I]n CBT it's a case of they've almost got, like, a checklist to work down. It's like, ‘OK, we've discussed this with thing, we've discussed that thing, we've discussed…’ and I felt like we weren't allowed to discuss anything outside of these checklist items.

While some saw the overall structure and predictability of a more rigid approach as attractive, other participants viewed a prescribed structure as having a negative impact upon their available time to think, explain or express ideas.

P2: A lot of people who are autistic … they don't know how to get the words out. They don't know that these words even exist to be able to explain how they're feeling. So just because someone goes ‘No’, that that doesn't work because they don't know how to explain why it doesn't work, so it's not just … because I've had a couple of friends get dropkicked by the service because they were just classed as ‘argumentative’ and ‘unwilling to participate’… And it was not that they were unwilling to participate – they don't know how. They don't know how to tell you … why it doesn't work, so it's again, it's working off-script and trying to help the person find the words that they need, because if you don't understand why it's not working, nothing will ever work.

Training and Adaptation

Broad Training

As described above, a concern among all participants was that their TTad therapist had apparently received little or no training about autism itself, its relationship with mental health or how it might impact upon therapy. Participants offered suggestions about the kinds of training that might help in the future, with some broad areas emerging. The first of these related to developing understanding of the links between autism and mental health.

P1: I think one of the most important things is understanding what autism is and like even just having a very general overview of what it is and how it can affect a person and because so much mental health is related to autism for autistic people. So, understanding like autism could be causing these feelings rather than it just being the depression or just being anxiety would help people be able to put things into context as well.

This was noted to require a greater understanding that autistic people might experience the physical environment differently to other clients:

P3: I think for me massively is know … ask what they’re sort of sensitive to like bright lights. If there's a flickering light bulb in room, you won't get me sitting there… That's another thing I've got to focus on.

The same participant also drew attention to how therapists might be trained to take better account of how an autistic person may communicate and interact.

P3: And so if you just like … if they just ask and it's more like would you like to tell someone face value how it is… I know it might seem really hard, but we are honest. There aren’t many autistic people I know that aren’t honest … like we are very blunt. So yeah, I’d say that and then accommodate to them.

Positive Adaptations

Finally, the participants were all able to point to ways in which their TTad therapists had made constructive adaptations. While these were not always described in terms of their specific therapeutic utility, they were all seen to have made it easier for the client to relax and/or communicate. Firstly, using understanding checks and not pressuring the participant for ‘quick answers’ were deemed to be key:

P1: She would always make sure that I understood everything. She would ask me what would like sort of help, which obviously at the time I wasn't entirely sure on, and she was also incredibly patient when I seemed to get like stuck on certain things that other people maybe wouldn't have gotten stuck on.

Similarly, being prepared to return to and rephrase questions where necessary, rather than ‘sticking to script’ was seen as immensely useful:

P2: She did her best and anything that was clearly not…. Anything she asked me and I didn’t give the answer that she was expecting, she’d then go back and reframe the question.

Participants reported that considering autism and mental health as inextricably linked, rather than as separate abstract entities, would be helpful:

P1: [S]he did always try and tie things back into the autism. So, while she wasn't trained in that, she did have a good enough grasp of what autism was … and actually like listened when I tried to explain my experiences with it. So then try and like tie in the obviously the behavioural therapy, homework tasks to the autism as well as the depression and the anxiety.

Discussion

This study has presented a detailed qualitative analysis of how five autistic people with depression and/or an anxiety disorder experienced referral to, and therapy within, NHS TTad services. This was undertaken as a phenomenological study of how autistic individuals made sense of this therapy in terms of their broader life experience, and not least their experiences in having been diagnosed with autism. Below, we consider our findings with respect to research literature and contemporary clinical guidance.

Participants described how their autism diagnoses had arrived after extended waiting periods and, in some cases, as outcomes of referral for key mental health conditions (Mandy et al., 2022). During these journeys, participants discussed how gatekeepers (often counsellors in schools and universities, though also GPs and others) had played crucial roles both in facilitating and impeding this diagnosis, whilst significant resistance from family and friends to them seeking (or even accepting) an autism diagnosis often featured in their narratives. Similar experiences are noted elsewhere in the literature, although it has also been reported that early autism diagnosis is not itself without risk to the autistic person (Lipinski et al., 2022; Okoye et al., 2023). Among the participants in the present study, such experiences were understood to be the consequence of others’ misconceptions and/or limited knowledge about autism. This emerged as a particular frustration when a lack of knowledge (or distorted knowledge) was experienced in healthcare professionals. Participants came to TTad pre-equipped with a particular sensitivity to lack of professional and lay understandings of autism, and this significantly affected their experience of therapy due to this, largely negative, experience of trying to make others understand. This sensitivity will need to be understood if successful therapy is to be undertaken.

The observations are drawn into sharper focus when it is considered how receiving an autism diagnosis fundamentally reshaped how participants understood and contextualised not only their specific mental health challenges, but broader life experiences in fresh and often positive ways. It legitimised their need for accommodations in professional and social settings and, in turn, reduced anxieties about ‘being themselves’ in social environments. It also facilitated access to formal and informal support networks, through a greater sense of shared identity with other autistic people (Botha et al., 2022; Cooper et al., 2023)

Previous research has similarly indicated that autism diagnosis, in adulthood, can lead to substantial affirmative psychological reframing of current and past experiences (Davies et al., 2024; Najeeb & Quadt, 2024). A therapist subsequently minimising the impact of an individual's autism during TTad work has the potential, therefore, to function as a core threat to that autistic individual's broader sense of identity and community.

There were significant mismatches between what participants felt they required from TTad services (and therapists), and that which was available. Central to this, and as noted above, was a concern that their autism had often been treated as separate from, rather than integral to, their mental health challenges. The primary therapy offered to the participants via TTad had been CBT, which is well-evidenced for treating anxiety and depression in non-autistic adults, and has been shown to be broadly effective for autistic adults at a national level in in England (El Baou et al., 2023). At an individual level, however, the participants in this study largely found that its structures did not support a specific autism-relevant understanding. Participants particularly highlighted how the rigid session structure did not account for the extra time it might take them to adapt to the questions asked, or the tasks required (Miller et al., 2025; Pappagianopoulos et al., 2025).

Similarly, the standard TTad assessment model requires individuals to record, rate and monitor their mental health as part of routine, sessional self-assessments. Some of the participants explicitly described a difficulty with ‘quantifying’ their feelings and experiences. Some autistic people struggle to conceptualise feelings in any conventional sense, with alexithymia a persistent state among many autistic adults, itself having complex links to anxiety and depression (Albantakis et al., 2020; Bloch et al., 2021; Kinnaird et al., 2019; Moore et al., 2022). However, the finding that some participants deliberately manipulated outcome scores to either stay in or leave therapy, underscores a ‘gamification’ principle. The notion that one might codify healthcare interventions using the mindset of complex modern video games has been explored, but there is less evidence around how the same mindset influences the practical use of healthcare interventions (Cheng & Ebrahimi, 2023). While the autistic participants involved in this study were rarely able to describe their own psychological states using the scales, they fully understood how the scores might technically ‘work’ in functional terms. This raises important questions about the validity of standard TTad outcome measures when applied to autistic people. While there is little doubt that non-autistic people can ‘game’ the system should they choose to do so, the implication here is that some autistic people can only game that system.

The importance of the therapeutic relationship emerged as a key issue for all participants, which aligns with literature on the importance of the therapeutic alliance in all psychological therapy outcomes for autistic populations (Brice et al., 2021; Cooper et al., 2023; Rodgers et al., 2024). Our findings, in concert with those of recent studies (Miller et al., 2025; Pappagianopoulos et al., 2025), suggest that therapeutic alliance with autistic adults may require specific adaptations to standard practice, including greater flexibility in communication styles, enhanced attention to sensory needs, and explicit recognition of how autism shapes mental health experiences, and may have shaped prior experiences with mental health services.

It became clear that some participants would control the TTad outcome scores as much based on whether they valued the therapeutic alliance as whether they felt the therapy itself was ‘doing any good’. This theme also suggests that autistic people's experiences became more positive over time, as their therapists made increasingly bespoke adaptations to their needs (Brice et al., 2021; Jubenville-Wood et al., 2023; Mazurek et al., 2023; Pappagianopoulos et al., 2025). This implies that therapeutic relationships within TTad services may require more time to develop effectively with autistic clients than standard service models presently permit.

Study limitations

This study has key limitations. Firstly, all participants were diagnosed as adults and had the capacity (and readiness) to engage in extended online interviews. This inherently excludes a population of autistic adults for whom the prospect of an online interview might be an inherently difficult prospect, no matter how sensitively framed. Secondly, our recruitment technique, using social media platforms, will have resulted in a sample of more digitally-engaged autistic adults. Thirdly, all participants were subject to England's public model of social healthcare, while individuals from a more notionally privileged background may have been able to find an autism diagnosis more rapidly through private healthcare services. Fourthly, as a study of autistic adults’ experiences of psychological therapies, some aspects of the findings may be specific to the NHS TTad setting. It should be noted, however, that this model forms a template for a number of international psychological therapy services, not least in Australia, Canada and Norway (Baigent et al., 2023; Knapstad et al., 2018; Vincent et al., 2021). The findings should, thus, have relevance beyond their original context.

Finally, a promise was made to all participants that no core demographics would be reported and linked together. This promise was core to the enhancement of uptake, given the sensitive matters at hand regarding experiences of a service they may continue to require, and its necessity was further underscored in the conditions of ethical approval granted. The lack of such reportage does, however, limit the manner in which sense can be directly made of participants’ accounts in terms of their own broader positionality.

Future Research

There are few studies that report the outcomes and experience of autistic people in high volume therapy services such as NHS TTad and the data presented here suggest that there are several potential problems that autistic people experience in such services. Research is needed to develop interventions to improve the experience and outcomes of autistic people. As also noted in the recent work of Pappagianopoulos et al. (2025) this may include outcomes of autism specific training for therapists, development of autism specific therapy interventions that can be used in NHS TTad services, and appropriate adaptations to service studies. On a more novel level, the observations regarding gamification, and an ability to only approach psychological metrics in the manner that one might approach a Role Playing Game (RPG) warrants investigation not only in terms of diagnosed autistic people, but as prospective insight into those without a formal diagnosis.

Conclusions

The observations made in his paper have prospectively important implications for service delivery within English NHS TTad and similar international programmes. They suggest a requirement for greater flexibility in service provision, more developed autism awareness among practitioners, and potentially extended treatment timeframes to facilitate effective therapeutic alliance development with autistic clients. While the study's limitations regarding sample characteristics and social media recruitment methods should not be overlooked, these insights nevertheless offer valuable direction for both service development and future research in this domain of mental health provision.

The findings emphasise that the journey to autism diagnosis was not a ‘mere’ precursor to therapy for the participants, but a fundamental context through which they filtered their subsequent therapeutic engagements and relationships therein. Moreover, the transformative quality of an autism diagnosis was evidenced to have reshaped participants’ entire understandings of their mental health challenges, and their core senses of self and community. Together, these matters draw attention to how any inferred minimisation of autism during an autistic adult's psychological therapy risks inflicting significant damage on therapeutic progress itself.

Supplemental Material

sj-docx-1-ndy-10.1177_27546330251350037 - Supplemental material for ‘They've Almost Got, Like, a Checklist to Work Down’: On the Lived Experiences of Autistic Adults Who Have Received a Structured Therapy Service for Depression and/or Anxiety Disorders

Supplemental material, sj-docx-1-ndy-10.1177_27546330251350037 for ‘They've Almost Got, Like, a Checklist to Work Down’: On the Lived Experiences of Autistic Adults Who Have Received a Structured Therapy Service for Depression and/or Anxiety Disorders by Paul K Miller, Natalie Dewison, Samantha LJ Bowden, Barry Ingham, Richard Thwaites and Dave Dagnan in Neurodiversity

Footnotes

ORCID iDs

Paul K Miller

Dave Dagnan

Author Contributions

Paul K Miller: conceptualisation, data curation, formal analysis, investigation, methodology, project administration, supervision, visualisation, validation, writing – original draft, writing – review and editing. Natalie Dewison: data curation, formal analysis, investigation, methodology, project administration, validation, writing – review and editing. Samantha L.J. Bowden: formal analysis, investigation, methodology, project administration, validation, writing – review and editing. Barry Ingham: conceptualisation, data curation, funding acquisition, investigation, methodology, project administration, resources, supervision, visualisation, validation, writing – original draft, writing – review and editing. Richard Thwaites: conceptualisation, data curation, investigation, methodology, project administration, resources, supervision, visualisation, writing – original draft, writing – review and editing. Dave Dagnan: conceptualisation, data curation, investigation, methodology, project administration, resources, supervision, visualisation, validation, writing – original draft, writing – review and editing.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by NHS England.

Declaration of Conflicting Interests

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

Supplemental Material

Supplemental material for this article is available online.

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