Zoe McFarlane with perspectives on good practice.
16 February 2026
'Autistic people have a high chance of developing mental health problems, but a low chance of receiving effective help.' As a late-diagnosed autistic woman myself, Dr William Mandy's words were extremely thought-provoking. I thought of the therapist I'd initially dreaded working with. We'd met on a course 18 months earlier, and I'd found her immensely irritating. When I was assigned to her for therapy, I groaned and called a friend to vent. I thought it would be a waste of time for both of us. It turned out to be some of the best therapy I've ever had.
We developed an amazing rapport, far stronger than with other therapists who'd looked perfect on paper. Later, I worked with a male therapist I connected with almost immediately… equally brilliant, but with almost nothing in common with the first therapist. What created that 'weird therapist magic', as one of my research participants later called it?
This question led me to conduct formal research as part of my MSc in Psychology: I interviewed 12 late-diagnosed autistic women about what made therapy feel genuinely positive for them. The research, which has been published in Autism in Adulthood and draws on appreciative inquiry methodology, revealed something important: good therapy for autistic clients isn't necessarily about special techniques or autism-specific interventions. It's about taking what we already know works and making it genuinely accessible. I think that this is essential knowledge for all therapists, not just those who specialise in autism.
Why should mental health practitioners care about autism?
Around 70 per cent of autistic people live with at least one mental health condition, compared to 17 per cent of non-autistic people. Yet for those who start therapy but don't complete it, two-thirds said that a lack of adjustments was a major factor: not because it wasn't working, but because the therapy wasn't accessible to them.
Here's the challenge: it's thought that 90 per cent of autistic people over 40 are undiagnosed. Many of your clients may be autistic without realising it. This is why I've tried to follow the maxim 'helpful to many, essential for some, harmful to none' in thinking about the following adjustments.
It's not all about autism, but autism matters
Autism isn't a mental health disorder to be fixed. None of my participants had sought therapy for their autism. One woman explained that autism affected "every aspect of that person's life", perceptions, experiences, and interactions with the world. It couldn't be parcelled up and put aside while focusing only on anxiety or depression.
As one person put it: "He accepted that I think differently to most of his other clients, and that it was OK. It was up to him to work out how to work most effectively with me."
Some research suggests practitioners provide less challenge to autistic clients, but my participants wanted to be challenged. They also needed therapy to provide what one described as a "safe and validating space":
"It felt really positive to have a place and time to go and just talk… it was completely non-judgmental and a welcoming environment where I felt accepted. I didn't always want to talk about traumatic things that have happened. Even if I was paying just to go to a completely accepting place where they didn't judge – that felt the most positive for me."
Building relationships
Social communication issues, including a difficulty in developing and maintaining relationships, are part of the core criteria of autism. The belief that autistic people lack empathy or theory of mind has pretty much been replaced by the theory of a double or even a triple empathy problem. Autistic people communicate differently; several studies have shown that in autistic only groups, many of the communication difficulties disappear. The problem isn't a deficit on behalf of the autistic person but a difference in communication styles.
My participants were clear about what helped them build therapeutic relationships. First, reliability mattered:
"She was always on time for appointments and did what she said she would do."
"He made sure to communicate that he was running late as soon as possible, because he knew that it would be an issue for me."
They wanted explicit boundaries and transparency:
"To build rapport I need honesty, transparency, detailed explanation and patience while I question that as much as I need to."
Empathy and collaboration
Whilst empathy is a core condition in mental health support it not only has to be shown but also perceived by the client. One of the points that my research highlighted was a difference in communicating and perceiving empathy which seems to be linked to autism.
Within the autistic community that autistic people often show empathy by sharing similar stories, something that can be misinterpreted as rude or attention-seeking. However, every single participant mentioned 'personal disclosures' as essential to the relationship. Not in an unboundaried way, but the careful sharing of some personal information:
"For them to share a bit about themselves too so that I can get to know them as a person a little before sharing so much of myself."
Hearing the practitioner had similar experiences built empathy and alliance:
"It made the therapist more human and easier to connect with."
Importantly, practitioners didn't need to be autism experts, with the wide range of autism presentation, what mattered was the willingness to work collaboratively:
"It feels collaborative. That's also how we work through misunderstandings, as there is the assumption that she might not know and we are there working it out together."
"She's open to not knowing something or wondering whether x or y"
"During my year-long therapy … I discovered that I''m autistic. My therapist embarked on the voyage of discovery with me … we worked out together which aspects of CBT were useful for me and they borrowed techniques from other modalities when appropriate"
Understanding autism without pathologising it
"Understand that every neurodivergent person is different and that there is no one thing that is true for all autistic people. Make sure you have an understanding of the fact that being autistic will affect every aspect of that person's life. It will just manifest very differently depending on who that person is and their experiences."
We all carry unconscious biases and internalised ableism. One study showed that whilst courses and training on autism reduced explicit bias, it was personal development, reflection, and supervision that had the greatest effect on implicit biases.
Participants mentioned this from both directions, helping clients recognise their internalised bias, and therapists recognising their own:
"He consistently picked up on the aspects of myself I saw as negative because they didn't conform to neurotypical norms and gently reminded me that those aspects weren't negative or 'bad', just different."
"[Therapists] need to recognise their own inevitable internalised ableism and work to dismantle that."
One practical example that was shared was:
"It isn't my thoughts or anxiety, for example, that make supermarkets or loud places overwhelming, it's because I'm Autistic, and it's upsetting when therapists don't seem to understand that part."
Participants wanted to build positive autistic identities, recognising strengths and celebrating positives:
"They will remind me that [autism] affects aspects of my life that I wouldn't have thought that it does, and so I feel completely accepted and understood as an autistic person in that room, and that it's completely acceptable for me to be the autistic person that I am."
Explicit acceptance of autistic behaviours
Rather than interpreting stimming or other autistic behaviours as having "unconscious meaning," therapists who built strong relationships offered simple, explicit acceptance:
"In the beginning I was often dissociated and very stimmy in sessions and this was met with complete acceptance, which was a new experience and built trust massively."
Managing transitions
Transitions, between sessions, and at the end of therapy, needed careful handling:
"What I found most difficult was literally putting the lid down on my laptop at the end of a session, which sometimes had been really challenging, and just being in my own house, without any change of scenery/walk/drive to help me mentally move out of the therapy session and back into everyday life."
Creating short, predictable routines for the start and close of the session, and having a (silent) clock visible can help autistic clients to prepare for the transition
Sensory differences
Up to 90 per cent of autistic people experience differences in sensory perception, creating challenges that can distract from therapeutic work:
"A sensory issue for me is wearing shoes, and I didn't feel I could take them off or ask to take them off as she would think it was weird."
This shows why conversations about adaptations need to be practitioner-led. Many clients will be embarrassed to ask or may not recognise the cause of their discomfort without prompting.
Cluttered noticeboards, ticking clocks, scents, and bright lights can all cause intense distraction or physical discomfort. Many areas now have 'expert by experience' groups who can audit spaces for sensory accessibility.
Sensory behaviours are often misunderstood. One participant said her therapist "would often interpret what I now understand as perfectly normal and common autistic responses as having 'unconscious meaning,' which made me feel othered and faulty."
The therapists who built strong relationships did simple things: they provided fidgets, explicitly gave permission to move furniture or take shoes off, and remembered sensory preferences from session to session.
"I think a bigger factor is the willingness to understand what I need."
Other adaptations that work
Processing time: "She also gives plenty of space and time for me to think and process. I never feel rushed. Minutes can pass by with me staring off somewhere trying to burrow down into something and she just waits until I ask her for help."
Alternatives to verbal communication: "Initially I did this by sending her emails before sessions about what I wanted to talk about because I found it too hard to verbalize."
"On bad days when I was struggling to speak, I wouldn't be pressured. He said to let him know when I was ready to talk, and he sat there quietly – or he would hand me a pen and paper and suggest that I draw or write instead."
Even physical positioning mattered: "We created a timeline of my life. To do this we sat at a desk side by side rather than facing, and I think this made it much more comfortable for me to open up and talk."
Good practice, made accessible
What encouraged me most in this research was the diversity of positive experiences participants shared. They described ten different therapeutic modalities. Six had positive experiences within NHS services. Both neurodivergent and non-neurodivergent therapists were described as providing excellent support.
This isn't about inventing new approaches or becoming an autism specialist. It's about recognising that the core conditions of empathy, congruence, and unconditional positive regard work for autistic clients too. They just need to be especially clear, transparent, and explicitly communicated.
The adaptations participants valued aren't burdensome accommodations, and as with the curb cut effect, they're often helpful to many other clients.
SIDEBAR: MAKING THERAPY ACCESSIBLE: FIVE PRACTICAL SHIFTS
Before the first session
Send information about what will happen, where to go, what to expect. Include details like: Is there a waiting room? Will they speak to a receptionist? How long will it last?
In the physical space
Offer options. Can lights be dimmed? Chairs without armrests? Less stimulating spaces available?
In communication
Be explicit. Ask directly about preferences rather than expecting clients to request accommodations. Use clear, concrete language. Check understanding frequently.
In planning
Suggest a focus for the session rather than asking open-ended questions. "I was thinking we could work on X today – how does that sound?" or "We could continue with X, or move to Y – which feels right?"
In follow-up
Offer written summaries or key points. This supports processing and reduces anxiety about "Did I understand correctly?"
Zoe McFarlane is Director of Coaching South West, providing CPD training for mental health professionals and coaching for autistic adults. She holds an MSc in Psychology and is a member of the British Psychological Society and the Association for Coaching. Her research, "A Qualitative Study Investigating the Positive Experiences of Therapy and Therapeutic Relationships of Late-Diagnosed Autistic Females" is published in Autism in Adulthood (2025).
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