A couple of years ago, I wrote an article entitled ‘An Autistic Therapist’, where I talked about the benefits of being autistic as a psychotherapist.
It has been three years since my diagnosis. Since then, I have come to understand a lot more about what makes a great therapist and how autism can play an essential role in becoming one.
Good & bad therapists
In 2018, Dr. Scott Miller described research showing that specific psychotherapist characteristics are essential to successful treatment.
When I heard about the research, I was dismayed to see that:
- 20% of therapists are getting 80% of the (excellent) results; while
- 42% of therapists are getting 20% of the results; and
- 38% of therapists are doing consistent damage to their patients!
What is even more astounding is that 93% of therapists believe they are in the top 20%. That means a substantial number of therapists who do consistent damage think they are doing a great job, even believing they are among the best!
Dr. Scott Miller and Dr. Jon Fredrickson specialize in teaching feedback-informed treatment (FIT), which helps clinicians gather input from their patients. Without this training, a therapist does not know where they fall in those statistics.
I have trained with both of these practitioners, whose goal is to teach therapists to achieve excellent results. My skill set puts me in the top 20% of therapists who do get 80% of the results.
So how does this relate to autism?
To be a good therapist, you must have a passion for research. Research comes at a steady rate, and without a drive for learning, it is hard to stay up-to-date. Being autistic, I have a natural desire to find out the truth and seek comprehensive understanding.
But it’s not just about informing my clinical practice. My clinic design is informed by research (such as Jamie Keaton Jones’ phenomenological study of the office environments of clinical social workers ), and the physical space is designed in accordance. Research shows that soft lighting, a tidy room, and personalization make patients feel more comfortable. I make sure my office looks welcoming, orderly, and homey.
Here is my office:
I sit in the chair next to the painting of hydrangeas, which I purchased from a patient who is an artist. I make sure there is cohesion in the colours in the room. As you can see, I include pastels and limit the number of colours. I believe it’s essential to establish a positive atmosphere. The colours cannot be too bold and diverse, or it becomes distracting or even anxiety-inducing. My patients have a choice to sit in four different places. Most people sit in the chair on the left side of the room, as pictured below:
They can also pull out the chair in the photo below. They may choose to sit on the floor on a cushion, in which case I will join them.
Research shows that patients feel more submissive if you have your degrees behind you in your office. As such, my degrees are not behind me in my office because I want my patients to feel like they are at my level. My degrees are in the waiting room instead, as you can see below.
Qualities of effective therapists
Now let’s go through the 13 qualities of effective therapists, based on research.
1. Effective therapists have an advanced set of people skills
- Listening skills
- Social and communication skills
- Ability to regulate and express emotions
- Warmth and acceptance
- Focus on the other
By the time an autistic therapist-to-be completes their psychotherapy training, they have had significant social training. As Anton Gollwitzer, a doctoral student in the Department of Psychology at Yale University said:
People with autistic traits are strong systemizers, and have an excellent ability to predict and analyze how people, in general, will react in a social situation.
Many of us have higher-than-usual empathy and use it to connect to our patients. In turn, patients feel understood and are able to form a secure attachment to us. Research supports that attachment is required from cradle to grave in all humans. Poor attachment is predictive of a lower quality of life, mental illness, and physical illness. But if a person can connect securely to a single person, we know that they can thrive emotionally, mentally, and achieve their potential.
The therapist creates these conditions in the first moments of interaction. In the initial contacts, patients are sensitive to cues of acceptance, understanding, and expertise. Although necessary throughout therapy, these conditions are most critical in the initial interaction to ensure engagement in the process.
A lovely quality of many autistics is their non-judgmental nature. I realize that some of us do judge, but the majority of us are just curious. My tagline in writing has for a long time been, ‘Wonder who a person is and they will amaze you’. Patients often comment as they express their darkest fears, that they see no criticism on my face and body language for criticism. Instead, they see is a curiosity and desire to understand them.
2. Effective therapists form a working alliance with a broad range of patients
A working alliance involves the therapeutic bond but also agreement about the goals of therapy. The working alliance is described as collaborative, purposeful work on the part of the patient and the therapist. An effective therapist builds on the patient’s initial trust and belief to form and solidify the alliance early in therapy.
A therapeutic working alliance is essential to therapy. I think many therapists do not understand the basics of what a working alliance is. The patient must express the internal emotional problem that they want to work on today. Patients get better when they clearly express the problem they want to work on—not the problem perceived by their partner, mother, etc. Therapists must NEVER assume what the problem is or project their own worldview onto the patient. I begin my sessions with, “What is the problem I can help you with today?” When the patient uses a defense, I reiterate the question. This allows them to enter a therapeutic alliance with me to get the results they desire.
For more information, on a working alliance, read the following article on my personal website:
3. Effective therapists provide an acceptable and adaptive explanation for the patient’s distress
Anyone who presents to a physician or psychotherapist wants an explanation for their symptoms or problems. There are several considerations involved in providing the explanation. First, the explanation must be consistent with the healing practice. In medicine, the explanation is biological, whereas, in psychotherapy, the explanation is psychological. Second, the explanation must be accepted by the patient. This involves compatibility with the patient’s attitudes, values, culture, and worldview. Third, the explanation must be adaptive. The explanation provides a way for the patient to overcome their difficulties. This induces positive expectations that the patient can master what is needed to resolve difficulties. Fourth, the scientific truth of the explanation is unimportant relative to its acceptance by the patient. The therapist is aware of the context, such as issues of culture, socioeconomic status, race, ethnicity, in the explanation’s development and presentation. Acceptance of the explanation leads to purposeful collaborative work.
This means cultural training is critical for your therapist. I took special training in counseling different cultures. It is not up to the therapist to decide what problem the patient has—it is ALWAYS up to the patient to decide what they want to work on. People with autism tend to be rule followers as long as the rules make sense. When we are taught as therapists to be culturally sensitive, we will likely look at the research and do extensive training.
4. The effective therapist provides a treatment plan that is consistent with the explanation provided to the patient
Once the patient accepts the explanation, the treatment plan will make sense, and compliance will be increased. The treatment plan must involve healthy actions. The effective therapist facilitates the patient to do something that is in their best interest. Different treatment approaches involve different actions, but the commonality is that all are psychologically healthy. Autistics are excellent at following rules and procedures.
Following a treatment plan that is consistent with our explanation is in our very nature.
5. Effective therapists are influential, persuasive, and convincing
A good therapist presents the explanation, and the treatment plan in a way that convinces the patient that compliance with the treatment will be of benefit. This encourages hopefulness, increased expectancy for mastery, and the enactment of healthy actions. These characteristics are essential for forming a strong working alliance.
I spend a lot of time in research and training in treatments that show high efficacy.
6. The effective therapist continually monitors patient progress in an authentic way
This monitoring may involve the use of instruments or scales or by checking in with the patient regularly. Authenticity means that the therapist communicates that they truly want to know how the patient is doing. Administration of scales, for instance, without a discussion with the patient, is insufficient. Effective therapists will integrate progress evidence into treatment and be particularly attentive to evidence that their patients are deteriorating.
Autistics excel at pattern finding, and patient feedback is no exception. I always give patients questionnaires or ask them directly how they have been since our last session. Without that, I would have no idea whether I have improved their set of symptoms.
7. The effective therapist is flexible and will adjust therapy if needed
Although the effective therapist is persuasive, patients may not accept the explanation and/or treatment or may not make adequate progress. The therapist is aware of verbal and nonverbal cues of resistance and uses evidence gleaned from assessing therapeutic progress with outcome instruments. The effective therapist takes in new information, tests hypotheses, and is willing to be wrong. Adjustments might involve subtle differences in the manner in which the treatment is presented, the use of a different theoretical approach, referral to another therapist, or use of adjunctive services (medication, acupuncture, etc.).
Research shows that if patients do not show improvement within the first 7 sessions, they are unlikely to improve with that therapist. Why focus on the therapist rather than the treatment? Well, it turns out, much like Alice in Wonderland’s ‘Everyone Wins,’ the efficacy of different therapies is about equivalent. What makes the difference is the therapist.
8. The effective therapist does not avoid difficult material in therapy
It is not unusual that the patient will avoid difficult material. The effective therapist does not collude to avoid the material but facilitates a discussion concerning core problems. Such discussions are typically emotional. Effective therapists must be comfortable with intense interactions. When this involves the relationship between the therapist and the patient, the interpersonal process is addressed therapeutically. This is sometimes called the “tear and repair” of the alliance.
Research shows that non-autistics process things from one vantage point only. However, autistics can process problems from two different vantage points. As an autistic, I can ‘dive’ into a patient’s emotional space to feel what they are feeling, then resurface to see things cognitively. By this means, I can choose the best evidence-based treatment for the patient and process what they are feeling from cognitive empathy.
9. Effective therapists communicate hope and optimism
This communication is easy for motivated patients who are making adequate progress. However, those with severe and/or chronic problems may experience relapses, lack of consistent progress, or other difficulties. Effective therapists acknowledge these issues. They continue to communicate that the patient will achieve realistic goals in the long run. This communication is not undue optimism but rather a firm belief that the therapist and patient will work together successfully. Effective therapists mobilize their patients’ strengths and resources to solve their own problems. Moreover, they demonstrate that through their own work, it is the patient who creates therapeutic progress. This encourages a sense of mastery.
I have been asked many times how I remain a trauma therapist day in and day out for over twenty-five years without quitting or having a breakdown. I always say the same thing—my patients get better, so I feel like I can help. I feel optimistic, as I have seen patient after patient recover and thrive.
10. Effective therapists are aware of the patient’s characteristics and context
Characteristics of the patient refer to the culture, race, ethnicity, spirituality, sexual orientation, age, physical health, motivation for change, etc. The context involves available resources such as socioeconomic status, family and support networks, vocational status, cultural milieu, and concurrent services. The therapist coordinates the patient’s care with other psychological, psychiatric, physical, or social services. Furthermore, the effective therapist is aware of how his or her own background, Big 5 personality traits, and status interact with the patient.
11. The effective therapist is aware of their own psychological process and does not inject personal material into the therapy
The effective therapist must reflect on his or her own reactions to the patient (i.e., countertransference) to determine whether these reactions are reasonable. One recommendation for therapists is that they attend regular counseling. Due to my autism, I have always followed that rule. I have found too many patients can tell what is going on in the therapist’s life based on the information that they give the patient.
For example, one patient who wanted to remove herself from an abusive marriage was told by her therapist that there were reasons her husband behaved that way. She found out that her therapist was beating his own wife.
I have always followed the proverb: Healer, heal thyself. As professor emeritus of medicine Jon Kabot-Zinn says:
It is critical that we as therapists do this work, because who else will? But it is also critical that we do not become caricatures of the very people we try to help.
12. The effective therapist is aware of the best research related to the patient in terms of treatment, problems, and social context
Of particular importance is understanding the biological, social, and psychological basis of the disorder or problem experienced by the patient.
I chose to do my Masters (in Science—Applied Psychology) in England because I felt they were advanced in their psychology research. The method that we were taught is called Case Formulation. Case Formulation requires three things:
- The patient as the expert in themselves.
- The therapist as an expert on the research and clinical experience; and
- Evidence-based research (EBR).
EBR is always the choice I utilize in my work with patients. I feel there is enough research on a variety of therapies for me to use that I do not need to use my patients like lab rats.
13. The effective therapist seeks to continually improve
Feedback on the progress of patients is critical to improvement. This allows the therapist to make specific changes and determine the outcomes produced. Evidence that a patient is not making satisfactory progress is useful, but knowing there is also insufficient agreement about therapy goals is key. Moreover, such information across patients detects general patterns. The effective therapist is one who achieves expected or more-than-expected progress while continually improving.
I do a lot of research. I observe patterns in behaviors and can often predict what people will do before they themselves know. This awareness, combined with empathetic concern and compassion, makes autistic therapists good at what they do.
There is also research specifically on why autistic people make good therapists. In 2019, an article was published entitled, Those with autism make good social psychologists. The article is based on research from 2019 by Anton Gollwitzer et al., which shows that:
- Autism traits predict slightly higher social psychological skills (based on ∼6,500 participants in 104 countries).
- Autism traits were found to correlate with social cognitive skills.
- Heightened systemizing is what leads to this greater social psychological skill (based on 400 participants).
What heightened systemizing (also called hyper-systemizing) refers to is that autistic people are great at analyzing systems and relationships and finding patterns, as research from 2009 by Simon Baron-Cohen shows. This ability to analyze systems will be focused on whatever our special interest is. For me, that special interest is human psychology.