Updated: Oct 19
Therapists often come into contact with people who may be autistic, but haven't yet been diagnosed.
Therapists may notice potential signs of autism during sessions, but it's important to proceed cautiously.
Symptoms that suggest autism could also indicate other disorders or life experiences.
Knowing what to look out for can help you tailor your approach and help clients access appropriate support.
If you're a therapist, it's highly possible that you have encountered clients who had level 1 autism‚—previously called Asperger’s syndrome—yet were unaware of it. I've heard many therapists say, with hindsight, that they wish they had known more about autism earlier so they could know what to look for in their clients.
Noticing how your client communicates with you could indicate autism, but there can be other signs as well. It's important to note that these signs are not necessarily definitive signs of autism and could also indicate different experiences or conditions. Still, they are helpful to keep in mind, especially if they coincide with other potentially autistic markers. If you've wondered, "could my therapy client be autistic?" the following discussion could be helpful.
Could my therapy client be autistic?
1. Repetitive motor behaviours
Restricted and repetitive behaviours are a core symptom of autism. These may include physical behaviours—such as head banging, rocking, flapping hands, or waving hands in the line of sight—or verbal behaviours, like repeating words or phrases during sessions(1). More subtle repetitive behaviours may include consistently picking at skin, playing with pens, foot rubbing, or repeatedly touching the face, neck, or hair.
There is considerable overlap between these types of behaviours and anxiety disorders, developmental disorders, or other neurodivergent conditions. Some specific behaviours, such as rocking and hand flapping, may be a clearer indicator of autism; still, these behaviours are not exclusively autistic and may indicate other conditions(2,3).
2. Cognitive inflexibility
Cognitive flexibility refers to our ability to adapt and respond to changing situations. Research suggests that autistic people often experience higher levels of cognitive inflexibility than the general population(4).
In therapy, we hope to help our clients explore themselves and others from different perspectives, encouraging them to see situations from someone else's point of view and become aware of their own biases. This process generally takes time with any client, particularly when they are strongly attached to deep-rooted beliefs.
Still, autistic clients may display a particularly inflexible approach during your work together. They might find it nearly impossible to understand a situation from someone else's perspective or to see the role their behaviour and thought processes play in interpersonal challenges. They may adopt a very inflexible position when talking about other people or fail to acknowledge or understand their role in a dispute.
3. Sensory processing
Atypical sensory processing is a core feature of autism(5). You might notice your client, for example, jump at a noise from outside or pick up on a noise you cannot hear. You may have some clients who are visibly affected by the light or scents in your office. Alternatively, you may have clients who are noticing and being triggered by all kinds of things but are too polite or feel it would be inappropriate to mention anything.
Sensory issues can also become apparent during conversations between therapist and client. Perhaps you have a client who mentions how difficult it is to go out for a meal because of the sound of scraping plates, or how horrific a trip to the supermarket is because of the lights and noise. Perhaps your client tells you they are sleeping separately from their partner because they cannot stand the way they breathe. Any of these could be a sign of sensory processing differences.
Sensory processing issues or hypersensitivity are not exclusively linked to autism—high sensitivity to noise could, for example, indicate anxiety or PTSD—but they often go hand in hand.
4. Strict routines and sensitivity to change
Rigid, routinised, and restricted behaviours form part of the diagnostic criteria for autism(6). Still, change can be difficult for anyone, and many people, autistic or not, prefer to live their lives in routine ways; in some cases, someone may create a sense of routine and order to help them feel protected and safe due to anxiety or past trauma.
This overlap can make it difficult to establish whether someone's need for sameness and routine is due to autism, an alternative condition, or simply a personal preference. However, if you have a client who becomes deeply upset when their routine is changed in even the slightest way and who seems to have a strong attachment to doing things the same way every day—and other potential symptoms of autism are present—it is worth considering autism as a possibility.
5. Emotional regulation issues
Autism is associated with poor emotional control and intense emotional responses.7 Yet the nature of therapy means that many clients may be dealing with emotional regulation issues and may feel like their emotions are out of their control during sessions.
While letting emotions run free during a session is often encouraged, autistic people may experience heightened and intense emotions in response to comparatively small triggers. Combined with other symptoms, becoming easily dysregulated during sessions may indicate autism.
6. Co-occurring disordered eating disorders
Many people develop eating disorders, for a wide variety of reasons. Yet there is a far higher occurrence of eating disorders in autistic people, especially women and girls, than in the general population. Research suggests that up to 30 percent of people with eating disorders may be autistic8—and given the amount of undiagnosed autistic people, it's possible that the true number is even higher.
7. Restricted interests
Autism is characterised by restricted interests. You might not only notice that your client talks excessively about one or two particular topics; you may also find it hard to engage with them about anything outside their narrow range of interests.
Someone who is autistic may also describe having relationships negatively impacted due to their engagement in their interests. In some cases, restricted interests may also interfere with them looking after their mental or physical health.
How Therapists Should Proceed
For an autistic adult who hasn't yet been diagnosed, learning that they’re autistic might be one of the most important, life-changing discoveries they’ll ever make. As their trusted therapist, sharing your views could pave the way for them to finally receive the right type of support and come to terms with their full identity.
Regardless, it’s always important for therapists to proceed with caution. Unless you are qualified to assess and diagnose your clients, you need to make it clear to your client that this is simply one option to explore, not a definitive answer. Pointing your client toward their primary healthcare provider should always be your first step.
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6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing; 2013.
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8. Solmi F., Bentivegna F., Bould H., Mandy W., et al. (2021). Trajectories of autistic social traits in childhood and adolescence and disordered eating behaviours at age 14 years: A UK general population cohort study. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 62, 75–85.