Part 1: Beyond Diagnosis – Clinical Reflections from the Consulting Room

In my previous article, How Autism Manifests in Psychotherapy: A Psychodynamic Perspective, I explored many of the psychological characteristics that may emerge when working psychodynamically with autistic adults. The aim was not to provide a diagnostic guide, but to consider how autism presents within the therapeutic relationship and how psychotherapy can help individuals understand themselves more fully.

This second paper has a different purpose.

Rather than revisiting established diagnostic criteria, it explores a number of clinical observations that have emerged during many years of psychodynamic practice. These observations should not be regarded as universal characteristics of Autism Spectrum Disorder, nor as established scientific conclusions. Instead, they represent recurring themes that I have encountered in psychotherapy with autistic patients over several decades. Some are supported by contemporary research, while others remain clinical hypotheses that I believe deserve further discussion and investigation.

One of the most striking changes I have witnessed throughout my career has been the transformation in how autism itself is understood.

When I first began practising, autism was usually associated with profound developmental difficulties. The image held by both professionals and the general public was often that of a child with severe communication impairments, significant learning difficulties and obvious behavioural differences. Adults with average or above-average intelligence who had learned to function relatively independently were rarely considered autistic.

Consequently, many people who would almost certainly receive a diagnosis of Autism Spectrum Disorder today were never assessed.

Looking back over many years of clinical work, I am convinced that I treated numerous patients who almost certainly met today’s diagnostic criteria but whose autism remained entirely unrecognised. Their anxiety, depression, relationship difficulties or occupational problems were addressed, yet the underlying neurodevelopmental differences shaping those experiences often remained unidentified.

This was not necessarily due to poor clinical practice.

Rather, it reflected the knowledge available at the time.

Diagnostic understanding evolves.

Clinical awareness evolves.

Society evolves.

Psychotherapy evolves alongside them.

One of the most significant developments has been the recognition of autism in women.

For many years, women were consistently underdiagnosed. Many learned from an early age to observe carefully, imitate social behaviour and conceal the difficulties they experienced internally. They often became exceptionally skilled at masking characteristics that might otherwise have led to earlier recognition.

As a result, some women reached adulthood having spent decades wondering why social situations felt exhausting, why relationships appeared so complicated or why everyday life seemed to require considerably more effort than it appeared to require for other people.

Many eventually received their diagnosis in their thirties, forties or even later.

For some, the diagnosis brought enormous relief.

Experiences that had previously seemed confusing or inexplicable suddenly became understandable within a coherent framework.

Many patients have described this not as receiving a label, but as finally receiving an explanation.

Psychotherapy often begins at precisely this point.

The diagnosis itself is rarely the end of the journey.

In many ways, it is only the beginning.

Once individuals understand that they are autistic, entirely new questions begin to emerge.

What aspects of my personality genuinely belong to me?

How much of my behaviour has developed through years of adaptation?

Where does masking end and my authentic self begin?

These are profoundly important psychotherapeutic questions.

They cannot be answered through diagnostic assessment alone.

They require careful exploration over time within a trusting therapeutic relationship.

The increasing availability of information has also transformed this process.

Today’s patients frequently arrive having read books, watched lectures, listened to podcasts and participated in online communities devoted to autism. Social media platforms contain thousands of individuals openly discussing their experiences, often describing aspects of autistic life that were rarely acknowledged publicly only a generation ago.

This increased awareness has undoubtedly helped many people recognise themselves and seek appropriate assessment.

At the same time, it has introduced new complexities.

Patients sometimes arrive with extensive knowledge about autism but relatively little understanding of how their own unique psychological development has interacted with their neurodevelopmental differences.

Two individuals may both identify strongly with autism while having entirely different personalities, histories, emotional lives and relationship patterns.

The diagnosis provides an important starting point.

Psychotherapy seeks to understand the individual.

This distinction remains fundamental throughout the therapeutic process.

Another observation that has become increasingly apparent over recent years is the growing openness with which autistic people speak about their experiences.

Many younger adults discuss autism with remarkable confidence and honesty. They often describe sensory sensitivities, social exhaustion, difficulties maintaining relationships, intense interests, emotional misunderstandings and experiences of masking with a degree of openness that would have been much less common several decades ago.

This represents an important cultural shift.

Psychotherapy no longer begins in an atmosphere where autism is experienced primarily as something to conceal.

Increasingly, it begins with curiosity.

Patients wish to understand themselves rather than simply hide their differences.

For the psychotherapist, this creates valuable opportunities.

The therapeutic work can move beyond simply reducing distress and towards helping patients develop a more coherent understanding of their identity, relationships, strengths and vulnerabilities.

In many respects, this represents one of the most encouraging developments in contemporary psychotherapy.

Greater public awareness has not eliminated the challenges associated with autism.

However, it has made it possible for many individuals to enter psychotherapy with something that earlier generations often lacked.

A language with which to begin understanding themselves

Part 2: Learning Through Observation, Memory and the Search for Meaning

One of the most interesting observations that has emerged repeatedly during my work with autistic adults concerns the way many appear to acquire knowledge about the social world.

Every child learns by observing others.

Children watch their parents, teachers, siblings and peers. They imitate behaviour, gradually developing language, social understanding and patterns of relating. This is a universal aspect of human development.

However, in psychotherapy, I have often observed that some autistic patients appear to rely upon observation and imitation to a considerably greater extent than many neurotypical individuals.

From an early age, they may become extremely careful observers of human behaviour.

They watch conversations.

They study facial expressions.

They memorise social rules.

They notice patterns of interaction.

Over time, many become remarkably skilled at reproducing what they have observed.

Some develop social behaviour that appears entirely natural to those around them.

Yet beneath this apparent fluency there may remain considerable uncertainty about why people behave as they do.

This distinction has become increasingly important in my own clinical thinking.

Observation and imitation may successfully reproduce behaviour.

They do not necessarily produce an intuitive understanding of emotional meaning.

This difference often becomes apparent within psychotherapy.

A patient may describe a conversation with extraordinary accuracy.

Every sentence may be remembered.

Every detail may be recalled.

The sequence of events may be reconstructed almost perfectly.

Yet when asked what another person may have been feeling, intending or communicating emotionally, considerable uncertainty may emerge.

The difficulty is rarely one of intelligence.

Many autistic patients possess exceptionally high intellectual abilities.

Some have extraordinary memories.

Others demonstrate remarkable analytical thinking.

Some have achieved distinction within highly demanding academic or professional fields.

The challenge often lies elsewhere.

It lies in translating observation into interpersonal understanding.

For this reason, psychotherapy frequently becomes a place where observation gradually develops into reflection.

The therapist is not primarily correcting behaviour.

Nor are they teaching social rules.

Instead, they are helping the patient become curious about emotional meaning.

Why might that person have responded in this way?

Could there be several possible explanations?

How might somebody else have experienced the same interaction?

What assumptions are being made?

These questions gradually expand the patient’s capacity to think psychologically about themselves and about other people.

Another interesting observation concerns the sources from which many autistic individuals learn about relationships.

Increasingly, patients describe spending large amounts of time learning from films, television programmes, YouTube videos, podcasts, books and social media.

This is entirely understandable.

When everyday social interactions feel confusing or unpredictable, observing relationships through structured narratives may appear considerably easier.

Films and television provide repeated opportunities to observe conversations.

Characters often express emotions clearly.

Relationships follow identifiable storylines.

Conflict is usually resolved within a predictable narrative.

These forms of observation may become important educational experiences.

However, they may also create difficulties.

The interpersonal world presented through fictional narratives is rarely identical to real life.

Characters are written to tell stories.

Conversations are carefully constructed.

Emotional reactions are often intensified for dramatic effect.

Relationships may become idealised or simplified.

Real life is considerably less predictable.

Consequently, some patients may unknowingly develop expectations about relationships that are influenced as much by fictional narratives as by direct interpersonal experience.

Psychotherapy provides an opportunity to examine these expectations with curiosity rather than criticism.

How were these ideas developed?

Where did these assumptions originate?

Do they reflect real relationships, fictional relationships or a combination of both?

This exploration often leads to a richer understanding of how each individual has gradually constructed their internal picture of the social world.

Another observation that has repeatedly impressed me concerns autobiographical memory.

Many autistic patients possess an extraordinary ability to remember events from many years earlier.

They may recall conversations almost word for word.

They remember dates.

They remember locations.

They remember clothing.

They remember precise sequences of events that occurred decades previously.

These memories are often astonishingly detailed.

Yet psychotherapy sometimes reveals an interesting contrast.

The factual memory remains vivid.

The emotional meaning may remain uncertain.

Patients frequently remember exactly what happened.

Understanding why it affected them so deeply may require much longer exploration.

Again, this illustrates the distinction that has become central throughout my own clinical work.

Remembering is not always the same as understanding.

Observation is not always the same as meaning.

Description is not always the same as emotional experience.

One of the principal aims of psychotherapy is therefore not to improve memory.

Many autistic patients already possess exceptional memory.

Rather, psychotherapy seeks to help transform remembered experience into understood experience.

As this process gradually develops, many patients begin noticing aspects of relationships that had previously remained outside conscious awareness.

Emotional intentions become clearer.

Misunderstandings become easier to recognise.

Alternative perspectives become easier to consider.

Experiences that once appeared confusing gradually begin to make psychological sense.

It is this movement—from observation towards emotional understanding—that remains, in my experience, one of the most rewarding aspects of psychodynamic psychotherapy with autistic adults.

Part 3: The Therapeutic Relationship, Emotional Regulation and Long-Term Psychotherapy

As psychotherapy progresses, the therapeutic relationship itself gradually becomes one of the most important sources of psychological understanding.

This is true in all forms of psychodynamic psychotherapy, but I have often found it particularly significant when working with autistic adults.

Many autistic patients enter therapy after years of adapting to environments that have felt confusing, unpredictable or emotionally overwhelming. Consequently, the therapeutic relationship frequently becomes one of the first relationships in which they experience a consistent, reliable and emotionally thoughtful environment over an extended period of time.

This consistency allows psychological exploration to develop gradually.

One observation that has remained with me throughout many years of clinical work concerns the importance of emotional regulation within the consulting room.

Some autistic patients appear capable of moving from emotional calm to considerable distress within a relatively short period of time.

At times, the trigger may seem surprisingly small to an outside observer.

A change in routine.

An unexpected misunderstanding.

A sensory experience.

A perceived criticism.

A disruption to carefully established expectations.

The emotional response, however, may be intense and entirely genuine.

Understanding these reactions requires considerable clinical sensitivity.

The therapist should avoid dismissing them as overreactions.

Equally, they should avoid becoming overwhelmed by them.

Instead, psychotherapy attempts to understand what emotional meaning the event has acquired for the patient and why it has produced such a powerful internal response.

Over the years, I have sometimes observed that these emotional reactions differ from those encountered in patients with borderline personality organisation, although superficially they may occasionally appear similar.

In my experience, the underlying psychological processes are often quite different.

The emotional response in autistic patients frequently appears closely connected to predictability, sensory experience, misunderstanding or disruption of an internal sense of order, rather than primarily reflecting the patterns of interpersonal instability typically associated with borderline personality organisation.

This distinction is clinically important.

Although similar behaviours may occasionally be observed, the psychological meaning underlying those behaviours may differ considerably.

Consequently, therapeutic interventions that prove helpful with one patient may be considerably less effective with another.

Psychotherapy therefore requires continual attention to the unique internal world of each individual rather than relying upon superficial similarities between diagnostic groups.

Another recurring observation concerns the importance of flexibility within the therapist rather than within the patient alone.

Psychotherapists often speak about helping patients adapt to life.

However, successful psychotherapy also requires the therapist to adapt thoughtfully to the patient’s way of experiencing the world.

This does not mean abandoning professional boundaries.

Nor does it mean colluding with every request or avoiding necessary interpretations.

Rather, it involves recognising that different patients require different therapeutic styles.

Some autistic patients respond particularly well to direct, clear and concrete language.

Others benefit from gentle humour.

Some appreciate carefully structured discussions.

Others require considerably more time before psychological interpretations begin to feel meaningful.

One aspect of therapy that has repeatedly surprised me is how valuable playfulness can become.

Many autistic adults retain an openness, curiosity and enthusiasm that can easily be overlooked because they simultaneously present as highly intelligent, academically successful or professionally accomplished.

When used appropriately, warmth, humour and genuine human engagement often become powerful therapeutic tools.

They help reduce anxiety.

They make psychological exploration feel safer.

They remind both therapist and patient that psychotherapy is not simply an intellectual exercise but a living human relationship.

Throughout my career, I have also worked with autistic patients over many years, and in some instances over several decades.

Long-term psychotherapy offers opportunities that shorter interventions cannot always provide.

Patterns that initially appear unrelated gradually reveal themselves.

Ways of thinking become more familiar.

Repeated interpersonal themes emerge.

Both therapist and patient begin recognising how similar emotional situations continue to recur across different stages of life.

The work therefore becomes increasingly reflective rather than merely problem-solving.

The therapist is no longer responding only to immediate difficulties.

Instead, both participants gradually develop a shared understanding of how the patient’s mind organises experience, relationships and emotional meaning.

Perhaps the most important lesson I have learned is that psychotherapy should never attempt to remove individuality.

The aim is not to make autistic people think, behave or experience the world exactly like everyone else.

Many characteristics associated with autism represent valuable ways of perceiving reality.

Exceptional observation.

Remarkable honesty.

Intellectual curiosity.

Original thinking.

Persistence.

Attention to detail.

These qualities deserve respect rather than correction.

Psychotherapy seeks only to reduce unnecessary suffering.

It aims to help patients understand themselves more fully, strengthen relationships where possible and develop greater freedom in responding to life’s inevitable challenges.

Looking back over many years of psychodynamic practice, I have become increasingly convinced that autistic individuals are often misunderstood not because they lack psychological depth, but because that depth is frequently expressed differently.

The task of psychotherapy is therefore not to force autistic patients into conventional psychological models.

Instead, it is to understand the unique organisation of each individual’s emotional life while recognising both the difficulties they face and the remarkable abilities they may possess.

Ultimately, successful psychotherapy is built upon curiosity rather than assumption.

The diagnosis provides useful knowledge.

Research continues to deepen our understanding.

Clinical experience adds further perspective.

Yet every new patient reminds us that no theory, however valuable, can ever replace the careful, respectful and thoughtful exploration of one unique human being sitting across from us in the consulting room.

It is there, within that relationship, that psychotherapy continues to teach us as much as we hope it teaches our patients.

Discussion Points

How has increasing public awareness of autism changed the way autistic individuals approach psychotherapy?

What are the advantages and challenges of learning social behaviour primarily through observation and imitation?

How can psychotherapists help autistic patients move from accurately describing experiences to understanding their emotional and interpersonal meaning?

What influence do films, television, social media and other forms of media have on the development of social expectations and relationships in autistic individuals?

How can exceptional memory and attention to detail become both strengths and challenges within psychotherapy?

Why is it important for psychotherapists to adapt their therapeutic style to the individual rather than relying solely on diagnostic labels?

How can long-term psychotherapy contribute to a deeper understanding of recurring emotional and relationship patterns in autistic patients?

What role do consistency, emotional steadiness and trust play in developing a successful therapeutic relationship with autistic adults?

How can psychotherapy help autistic individuals recognise and build upon their strengths while addressing areas of emotional difficulty?

In what ways can psychodynamic psychotherapy contribute to a more individualised understanding of autism beyond diagnostic criteria alone?

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