Show me the real you: Therapeutic relationship-building with autistic adults

Abstract

Research in psychotherapy and counselling theory has investigated the significance of the therapeutic relationship for decades, demonstrating its impact on service outcomes across settings, client groups, and therapeutic orientations. At the same time, research shows that autistic adults often do not experience positive relationships with professionals, and that many of their healthcare and support needs are unmet. Despite this extensive knowledge, relationship-building appears to be neglected in the context of working with autistic adults. At best, existing literature recommends ‘different’ approaches, based on the assumption of low social motivation and relational deficits in this client group. At worst, it suggests that relationship-building with autistic adults is too difficult to be worth the effort. Grounded in the neurodiversity paradigm, this thesis shifts the focus from presumed unilateral social deficit in autistics to bilateral differences in relating, or the ‘double empathy problem’. I interviewed 17 autistic adults about their relationship-building experiences with a wide range of professionals, with the majority working in mental health contexts. I also interviewed two mental health counsellors and one psychologist, who all had experience working with this client group and had been recommended by autistic participants. I elicited best-practice recommendations from all participants and analysed interviews in an interpretive-interactionist framework. The results are presented in both standard academic form and through found poems created from the words of the participants. Three main themes emerged: One, a shift from access (reasonable accommodation of sensory and cognitive needs) to ‘access intimacy’ (proactively embracing sensory and cognitive difference) created a sense of safety and welcome for autistic adults, which functioned as a strong basis for ongoing relationship-building. Two, professionals whose practice was informed by the neurodiversity model appeared to be more successful at building relationships than those who based their interactions on the medical model. They did not conceptualise their clients as flawed or in need of adapting to the non-autistic majority. Instead, these successful professionals saw their autistic clients as members of a minority culture and attempted to adapt to them, showing curiosity, cultural humility, and awareness of ingrained power dynamics. Three, different approaches were not needed for relationship-building with autistic adults. Instead, the most important variables identified by the participants (authenticity, empathy, and feeling liked) aligned strongly with Carl Rogers’ relationship conditions (congruence, empathy, and unconditional positive regard). Participants described pivotal relationship-building moments associated with enhanced expression of these conditions. Based on my analysis of participants’ thoughts, experiences, and ideas for improving therapeutic relationships, I make several recommendations for enhancing professional practice. These recommendations range from the creation of a national online database of accredited, neurodiversity-affirming professionals, to detailed, practical suggestions that practitioners, clinicians, and researchers can implement immediately to enhance their relationships with autistic adults.