Identity-Affirming Approaches for Autistic Clients: Therapists Best Practice
Author: Vauna Beauvais, psychotherapist and autistic person.
The Role of Identity in Supporting Autistic Clients
This article explains the relevance of autism identity to mental health and wellbeing. It is intended for counsellors and psychotherapists working with autistic clients. Developing a positive autism identity can have challenges for autistic adults. Facilitating autism identity development is an important therapeutic process because research shows a link between positive autism identity and improved self-esteem and wellbeing. However, barriers like stigma and lack of acceptance impede identity formation. Counsellors and psychotherapists play a vital role in utilising identity-affirming practices to affirm autism as a natural difference, not a deficit and transform difference into diversity. This article offers guidance for therapists working with autistic clients and offers insights in fostering affirmative identity which contributes to empowering clients to fully embrace themselves and increase well-being.
Autism and being autistic
Autism was historically viewed from a deficit-based medical model focusing on within-person deficits, and existing as a diagnostic label or a medical condition. Insights from the neurodiversity paradigm (promoted through the neurodiversity movement) purport that neurological differences is natural human variation, and not something to cure (Aftab, A. and Chapman, R. (2021).
For an individual, a sense of personal identity allows a way to be distinguished from others and be defined as unique. While a social identity aligns the self with a collective through shared traits and experiences. The core autistic characteristics that are integral to who an autistic person is, is a facet of their personal identity, in relation to their uniqueness. And being autistic informs their social identity due to being part of the population of autistic people.
A person’s sense of connection and membership within a group is intrinsically tied to their sense of self and personal identity because our affiliations and associations shape our understanding of self, based on the groups we belong to. Identifying as ‘one of the group’ is an innate and primary source of pride and self-worth, or of shame and stigma.
All humans are worthy, and all populations of people have equal worth, which is unrelated to the size of the population or the power they hold. Autistic people, as a collective, are in a minority as a population of human beings, and each individual within that population is an autistic person. People in minority populations share experiences that are commonly found among people in that population, as well as having individual experiences based on their uniqueness as a person and related to the intersectionality of their status and positions in domains of life.
Many autistic adults have not ‘known’ that they are autistic until recently. Or, you could say that they have always known some things about themselves, but they didn't before have access to ways of conceptualising, examining, naming, and exploring realities of themselves. And now that they can they have the opportunity to gain the clarity and learn more about themselves by access to information about autism and autistic people. ‘Being autistic’ adds another layer of ‘who I am’ to my identity.
Struggles with embracing autism as a facet of identity
In my work as a therapist seeing autistic adult clients, I have found that there are often struggles with developing an affirmative autism identity. Some contributing factors have been facing barriers like lack of acceptance from others (which may encourage a person to diminish or extinguish the significance of being autistic in order to keep others feeling comfortable or to avoid social rejection or disharmony). And I’ve noticed clients talk (on reflection) about having other difficulties, such as even thinking of themselves as ‘being’ autistic caused by shame from internalised stigma, or that they avoided engaging with thinking it through due to overwhelm or a sense of engulfment from ‘Autism is everywhere’. Additionally, I’ve been with clients experiencing fear or helplessness from a sense of having ‘everything that was once known being now unknown’ and experiencing a loss of security from certainty or self-trust, and, in some cases, clients have said that they experienced confusion and anxiety and a loss of control.
The relevance of a positive autistic identity on mental health.
Just like forming other social identities, developing an identity as an autistic person is a key process. And researchers have questioned whether there is a link between ‘acceptance and positivity’ about being autistic and an individual’s mental health. Many researchers have found that developing a positive autistic identity does, indeed, relate to greater self-esteem and well-being for autistic people, and have shown that anxiety, depression, distress, and stress is found to be higher in autistic people who have not found ways to embrace and own their autisticness in ways that work for them and their lives (Bortha, M. & Frost, D.M. 2020; Cage, E., Di Monaco, J., & Newell, V. 2018; Cooper, K., Smith, L. G. E., & Russell, A. 2017).
It is already established now, that minority groups face unique experiences related to their minority identity that have negative effects on their mental health (Bortha, M. & Frost, D.M., 2020; and Mereish, E. H., & Poteat, V. P. 2015). Often, but not always, harmful things happen in covert ways which are difficult to articulate or to persuade others of the reality, such as exploitation, victimisation, microaggressions, everyday and lifetime discriminatory experiences from interpersonal encounters, as well as from the impact of structural marginalisation and oppression. Not only is the harm done, but also the individual may be silenced about it or not believed, and the impact of the experience is accordingly compounded by being gaslighted. The impact causes a lot of harm in a subtle way. The stress-effect builds up and leads to physical and mental health disparities in minority populations and this is well evidenced and documented in the research literature. The aforementioned authors assert that developing a positive identity actually buffers the impacts of minority stress and that is why it is so crucial for good mental health and wellbeing.
It seems to follow, then that counsellors and psychotherapists have an important role to play in facilitating clients’ identity development as a part of the therapeutic process. Identity-affirming counseling practices are especially vital for autistic people, precisely because autistic clients are members of a marginalised group and are, accordingly impacted by minority stress (whether the person knows that they are autistic or not). And, given that we work with clients as individual people, and each of our clients have different experiences of discrimination or disadvantage due to the intersectionality of their social identities, the relevance of autism identity-affirming alone varies from person to person and needs to be approached in the context of that person’s whole identity.
Autistic people are not ‘non-human’ (even though that has been thought and written about throughout history, see “Humans, aliens & autism” by Ian Hacking, among other works). Autistic people are people, and all people desire connection with others.
As therapists, we are used to appreciating client’s individual model of the world and including their values and needs in assessing what is a meaningful happy life, and that is no different when we interact with a client who is autistic.
Psychological growth and development occurs through interpersonal relationships, as does psychological damage. And if we situate minority stress within a relational framework we can say that impact of the aforementioned harms leads individuals to internalise and develop self-concepts that guide how they relate to others and how they perceive themselves. Moreover, it shapes how they treat themselves, what they come to expect, and the decisions that they make about who they are and what life they can have.
The Nature of Autism Identity
Autism identity - ‘being autistic’ - acknowledges both individual and collective aspects, as part of one’s overall self-concept (Cooper et al., 2017). On the personal level, it involves an individual’s specific autistic traits, values, and experiences that make them unique. The social facet relates to connections and commonalities with the broader autism community (Sinclair, 1993; Cooper et al., 2017).
Since being autistic forms a central part of personal and social identity, counsellors and psychotherapists working with autistic people can recognise the benefits of autistic people belonging to a community of autistic people (Bortha, M. & Frost, D.M. 2020). Ideas about connecting with an autistic community can include social media group threads, or in-person or online meetups, or passively enjoying publications and videos of autistic people talking about being autistic. Clients have said to me that simply reading autistic lived-experience blogs, or watching videos of autistic people talking about everyday life and being autistic, is beneficial. And to paraphrase from the collection of comments that I have heard from clients repeatedly, they say, “To find there is a world of autistic people is amazing. It really helps to know that there are millions of us out there, and I am not alone, and that I have my equally valid place in the human race among all others”.
In Summary
While a positive autistic identity contributes to better mental health, there are challenges for autistic adults in developing an autistic identity. This has implications for therapists working with autistic clients. Therapists must incorporate this into their work with autistic clients and use a neuro-affirming approach borne from their own positionality of autism as a positive identity. Therapists can develop their positionality by reading, being informed by the neurodiversity paradigm, exploring their own biases and prejudices, and understanding real autistic people as human beings and clients to be understood when we have the privilege of working together as their therapist.
Challenges in developing an autistic identity
Autistic people contend with numerous barriers to developing a positive identity, which can undermine self-esteem and well-being:
Lack of acceptance from parents, professionals, and society. Many people still see autism as inherently negative (Cooper et al., 2017).
Late or missed diagnosis. Without knowing that you are autistic, it’s impossible to develop identity. While understanding that people recognise themselves as autistic before they go for an assessment and diagnosis (if they even ever do, as it’s a personal choice, with pros and cons related to each individual) I have found a report that states that the average diagnosis age is 6 for children, and age 31 for adults (Lai & Baron-Cohen, 2015).
Internalised stigma about autism is absorbed from others (Cage et al., 2018). Common stigma includes that autism is a disease, is inherently disabling, or that autistic people are wrong, bad, unacceptable, tragic, or ‘too much’.
No access to autistic communities. Contact with similar others aids in identity formation
The medical model's interest in causation and cure. Celebrating autism as an inseparable aspect of identity and person-first language centers identity on “personhood” not autism, and implies that autism should be separated from the self rather than being a fundamental part of who you are (Kapp et al., 2013).
Implications for Therapists: Neurodiversity-Informed Therapy for Autistic Clients
Taking into account that identity is multifaceted, and being autistic may be central for some clients and not for others, we can celebrate clients’ self-expression and autonomy in determining their identity their way, and at their own pace.
However therapists should engage in identity-affirming practices that convey acceptance and addresses stigma regardless. And when relevant and appropriate, support clients in connecting with community in ways that appeal to them.
Therapists’ neuro-affirming approach can include:
Use identity-first language. Say “autistic person” rather than “person with autism” to affirm autism as an identity, not an accessory (Kapp et al., 2013). (However, deferring to clients’ terminology preferences is essential).
Provide acceptance and validation of the client’s identity as an autistic person. Affirm autism as a positive difference, not a deficit. And while being autistic is not something wrong or unfortunate to be changed or hidden, abide with clients as they explore with you the conflicts of taking that onboard personally, and the realities of ‘wearing’ that in various social domains (which may very likely incur risks to be known and mitigated).
Make clients aware that there is a ‘community’ that they belong to and that they can choose to interact in online forums, and groups and events (online and offline) if they want to, as well as hear the chorus of autistic voices broadcasting on the internet about their everyday lives, struggles, rants, joys, and accomplishments. Cage et al., purport that this solidifies that being autistic is normal and that it aids identity development (Cage et al., 2018). On a personal note, as a late-identfying autistic adult myself, I know that seeing other autistic therapists and speaking with them (many of whom are now colleagues and/or friends) was eye-opening for me and did, and does, deepen my own comfort and security in my autistic identity.
Explore clients’ feelings about ‘autism’ openly. Be prepared to recieve both negative and positive beliefs, and honour and stay with your client throughout. To be informed, read about the Neurodiversity Paradigm, and help clients develop positive narratives about autism through a neurodiversity lens.
Provide space to understand and for autistic identity to be placed comfortably. Therapeutic conversations may include processing a diagnosis, grieving late identifucation and the associated realisations and consequences of not knowing, working through internalised stigma and de-shaming (Gallardo et al., 2009).
Conclusion
Developing a positive autism identity is crucial for supporting self-esteem, wellbeing, and sense of belonging for autistic clients. Therapists play an integral role through identity-affirming practices. Given that in our work we get to know a person who is our client, and the client gets to know themselves more in ways that is useful for what they have come to therapy about, conceptualising autism as an identity transforms difference into diversity, and diversity is underpinned by belonging and worth, rather than rejection. Quite apart from what a client may have presented as their reasons for coming to therapy, deepening the development of a positive autistic identity enables clients to embrace themselves as authentically autistic, which furthers self-acceptance and contributes to psychological health.
Do you like this article and want to be involved in training and events based on these principles?
Vauna Beauvais is a psychotherapist in private practice and a trainer at Vanguard Neurodiversity Training. Our Certificate course starts again September 2024. Get in touch if you would like to talk and explore whether this is right for developing your work with neurodivergent clients.
References
Aftab, A. and Chapman, R. (2021) The Neurodiversity Paradigm in Psychiatry: Robert Chapman, PhD. Psychiatric Times. Retrieved February 11th 2024 from: https://www.psychiatrictimes.com/view/neurodiversity-paradigm-psychiatry
Bortha, M. & Frost, D.M. (2020) “Extending the Minority Stress Model to Understand Mental Health problems Experienced by the Autistic Poplulation” Society and mental Health. Vol 10 (1). American Sociological Association.
Cage, E., Di Monaco, J., & Newell, V. (2018). Experiences of autism acceptance and mental health in autistic adults. Journal of Autism and Developmental Disorders, 48(2), 473-484.
Cooper, K., Smith, L. G. E., & Russell, A. (2017). Social identity, self-esteem, and mental health in autism. European Journal of Social Psychology, 47(7), 844-854.
Gallardo, M. E., Johnson, J., Parham, T. A., & Carter, J. A. (2009). Ethics and multiculturalism: Advancing cultural and clinical responsiveness. Professional Psychology: Research and Practice, 40(5), 425.
HACKING, I. (2009). Humans, aliens & autism. Daedalus, 138(3), 44-59.
Jones, L., Goddard, L., Hill, E. L., Henry, L. A., & Crane, L. (2014). Experiences of receiving a diagnosis of autism spectrum disorder: A survey of adults in the United Kingdom. Journal of Autism and Developmental Disorders, 44(12), 3033-3044.
Kapp, S. K., Gillespie-Lynch, K., Sherman, L. E., & Hutman, T. (2013). Deficit, difference, or both? Autism and neurodiversity. Developmental Psychology, 49(1), 59.
Lai, M. C., & Baron-Cohen, S. (2015). Identifying the lost generation of adults with autism spectrum conditions. The Lancet Psychiatry, 2(11), 1013-1027.
Mereish, E. H., & Poteat, V. P. (2015). A relational model of sexual minority mental and physical health: The negative effects of shame on relationships, loneliness, and health. Journal of counseling psychology, 62(3), 425.
Sinclair, J. (1993). Don't Mourn For Us [Pamphlet]. Syracuse, NY: Autism Network International.