10 Ways to Support Autistic Clients in CBT Sessions
As CBT practitioners, many of us are seeing more clients who receive a late diagnosis of autism — often in their 20s, 30s or later. I’ve had clients say, “It explains everything now” — the years of feeling different, misunderstood, masking, struggling socially or emotionally, now reframed. But the flip side is that these adults often have trouble recognising their strengths: strengths that have been overlooked, suppressed, or taken for granted. The following are 10 ways to adapt and enrich CBT sessions for autistic clients, especially those diagnosed late, with clinical techniques, strengths‐based framing, and some illustrative vignettes.
1. Begin With Narrative of Difference & Discovery
When someone is late‐diagnosed, the diagnosis can feel like a relief — a coherent story for past suffering. Starting the work by inviting clients to tell their life story through that lens — what they didn’t know, what they felt misunderstood about, what adaptations they made — can help build clarity and trust.
Technique: In the first few sessions, include a guided timeline exercise (possibly visual) where clients map key life moments (school, work, relationships) and overlay moments of confusion, ache, and also moments of hidden success or coping.
Vignette: I had a client in his 40s, never diagnosed, who realised that what he had thought were “failures” in social situations were often times when he was sensitive to sensory overload; once we drew that timeline, he could see many times he’d solved problems via coping strategies (structure, routines, withdrawing early) and that these were strengths to be honoured and worked with, not “symptoms” to just suppress.
2. Adapt Thought Records & Cognitive Restructuring
Traditional thought records can be heavy on verbal abstraction, which may be hard for some autistic clients. Adapt them: use more concrete prompts, visuals, multiple‐choice options, allow more time for processing.
Technique: Offer templates with visual scaffolds (drawings, flowcharts), or allow a version where the client fills in parts in writing vs speaking vs drawing. Use simpler “if‐then” structures. For example, instead of “What’s the evidence for and against this thought?”, try “What happened → What I thought → What I felt → What I might try instead.”
Vignette: A late‐diagnosed client of mine was very good verbally but still found the “evidence for/against” column abstract. I adapted by drawing a two‐column chart and letting them use photos or sketches as metaphors; they said seeing their thought “visually laid out” helped them challenge more effectively.
3. Use Strengths Assessment Early & Regularly
Because strengths are often unseen or internalised (especially when people have felt “off” all their life), explicitly assessing strengths is essential.
Technique: Early in therapy, use tools or worksheets that elicit self‐reported strengths (personal, cognitive, social, creative). Revisit these regularly. Use them not as a sidebar but as building blocks for goals and interventions.
Vignette: One client, late diagnosed, always dismissed their special interest in pattern recognition because friends saw it as odd. We used a strengths inventory, and they identified analytical pattern skills; we then wove that into behavioural experiments (e.g. using pattern tasks when anxious, as grounding) and into their occupational goals. Not only did anxiety reduce, but quality of life increased because they felt more themselves.
4. Structure & Predictability with Flexibility
Many autistic clients value structure, clarity about what to expect; but rigid structure without flexibility can feel oppressive. Balance the two.
Technique: Begin each session with a brief agenda, perhaps shared visually. Signal key transitions. Use check‐ins about pacing. Be ready to adapt if the client is overwhelmed (e.g. sensory issues, fatigue).
Vignette: I once planned a session full of emotional exposure work but the client arrived after a long, noisy commute, exhausted. We paused, used half the session to ground and restructure, then deferred the exposure. That afternoon they emailed: “Thank you for not pushing — I felt heard.” Trust builds with that kind of responsiveness.
5. More Experiential & Behavioral Work
Because abstract verbal processing can be draining or less accessible for some, emphasising behavioural experiments, role‐plays, exposure, activities, art, sensory work can help make CBT more “felt” and less purely cognitive.
Technique: Use role plays, in vivo or virtual exposures, behaviour experiments that tie into the client’s life. If possible, integrate interest‐based themes (e.g. using a client’s special interest as content in behavioural experiments).
Vignette: A woman diagnosed late in life loved woodworking. When she had social anxiety about public speaking at work, we did exposure work involving demonstrating a woodworking technique to colleagues (something she was already good at). It reduced anxiety, and the exposure felt more meaningful and less “clinical”.
6. Sensory & Communication Adaptations
Sensory overload, communication style mismatches, masking — these are often underacknowledged but hugely important.
Technique: Check in regularly about sensory needs (lighting, noise, temperature, timing). Use clear, unambiguous language. Avoid idioms unless clarified. Allow extra latency for processing. Consider written summaries.
Vignette: One client always felt anxious about the waiting room lights. After we adjusted timings and offered a quieter waiting space, their session focus improved. Another preferred “tell me three ways you think of saying this thought” rather than me pushing for the “best” way.
7. Recognise & Work With Masking / Camouflaging & Self-Criticism
Late diagnosis often means long years of masking — hiding ‘autistic parts’ to try to fit in. Masking can lead to exhaustion, self‐criticism, imposter feelings. CBT can help gently unpack this.
Technique: Use schema work or parts work to explore what the client has done to mask, at what cost; cognitive restructuring around self-criticism rooted in masking; behavioural experiments that allow small acts of “unmasking” in safe contexts.
Vignette: I had a client who for years mimicked social behaviours verbatim, to “pass.” We explored what felt authentic vs what felt like performance. As therapy progressed, they tried reducing masking in one social area (with friends) and noticed anxiety first, then relief and less exhaustion. That became a core goal.
8. Tailored Pacing & Session Length
Some clients fatigue, especially those diagnosed late, because years of “being on guard” are exhausting. Psychological work, especially cognitive work, compounds that.
Technique: Offer break times, consider shorter or more frequent sessions instead of the standard one once per week; possibly homework that is flexible or “low effort” when needed. Use check‐in at session start about energy levels / availability.
Vignette: One client I saw wanted deep sessions, but after 50 minutes would be exhausted, leading to drop in engagement. We tried 40 minutes + 20 minute “wrap up” check, sometimes via email; it preserved momentum without overwhelming them.
9. Embed Strengths into Goal-Setting & Progress
Too often goals are pitched as “reduce that symptom,” “stop that behaviour,” without enough of what the client wants to build, who they want to be, what skills or qualities they want to strengthen. Embedding strengths gives meaning and boosts motivation.
Technique: When setting goals, ask: “Which of your strengths could help you reach this goal?” Use growth‐oriented, values‐driven goals, not just problem remediation. Regularly review progress not only in symptom reduction but in strengths growth and quality‐of‐life gains.
Vignette: A client whose emotional sensitivity had been a source of shame started to see it as a strength in empathic listening. One goal was “to use my empathy to support others” rather than simply “to reduce feeling overwhelmed by others’ feelings”. Tracking times when empathy helped others became part of therapy, not just times it hurt.
10. Be Explicit About Therapeutic Alliance & Autonomy
Many autistic clients who are late‐diagnosed have had experiences of being pathologised, misunderstood, or having support imposed. Being explicit about working with them, not on them, helps build safety.
Technique: Co‐construct treatment plans, invite feedback frequently, check that interventions feel respectful, adjust when client’s autonomy feels compromised. Use transparent communication about what we’re doing, why, and how.
Vignette: One client told me early on, “In previous therapy I left feeling like I was the experiment.” So in my plan with them, I shared rationale, invited them to pick which techniques felt tolerable, and let them veto exposures if needed. That kind of participatory approach raised trust dramatically.
Recent Research & Implications
Here are some of the more recent studies that have implications for practice with late-diagnosed autistic adults or autistic clients more broadly, especially in respect of strengths, adapting CBT, and comorbid mental health:
- Self-reported strengths and talents of autistic adults (Lampinen et al., 2025): In a study of 127 autistic adults, themes of strengths included cognitive/executive functioning, character strengths, creative/artistic ability, academic, interpersonal. Age of diagnosis related to what strengths were noticed/self‐reported. PubMed
- Strengths use predicts quality of life, well-being and mental health in autistic people (Taylor et al., 2023): Using strength‐based interventions and increasing use of self-identified strengths shows promise for boosting well‐being and mental health outcomes. PMC
- Psychosocial therapeutic approaches for high-functioning autistic adults managing core symptoms & comorbid anxiety/depression (Schweizer et al., 2024): Emphasises the importance of adaptations in CBT for communication, pacing, sensory modulation, and tailoring interventions to client profile. PMC
- A conceptual perspective on the role of cognitive & behavioural factors in anxiety within ASD Level 1 (Prasanna et al., 2024): Highlights mediators/moderators (e.g., cognitive flexibility, executive function, environmental support) in determining CBT outcome, and argues for scaffolded, flexible, adaptation‐rich CBT protocols. SpringerLink
- Development and adaptation of a strength-based job interview intervention (KF-STRIDE) (Genova et al., 2023): Focused on transition‐age youth, but the model of identifying strengths, then practising expressing them (in this case for interviews) offers a paradigm that can be adapted in therapy. Frontiers
Conclusion & Next Steps
Working with autistic clients (especially those diagnosed later in life) in CBT is enriched when we approach therapy not just as symptom relief, but as partnership in identity, growth, and empowerment. By deliberately weaving in strengths, adapting technique, being flexible and transparent, we honour not just what has been challenging for them, but also what has always been resilient and powerful.
If you’re a CBT practitioner looking to deepen your competence and confidence in this work, I’ll be running a webinar:
Working with Autistic Clients in CBT
with Prof Patrick McGhee
Sign up here →
In that webinar we’ll go deeper into case examples, live adaptation exercises, and strategies you can apply immediately.
References
- Lampinen, L. A., Singer, J., Wang, X., VanHook, B., Wilkinson, E., & Bal, V. H. (2025). Self‐reported strengths and talents of autistic adults. Autism. PubMed
- Taylor, E. C., et al. (2023). Strengths use predicts quality of life, well‐being and mental health in autism. PMC
- Schweizer, T., et al. (2024). Psychosocial therapeutic approaches for high-functioning autistic adults managing core symptoms & comorbid anxiety/depression. PMC
- Prasanna, N. V. T., et al. (2024). A conceptual perspective on the role of cognitive & behavioural factors in anxiety within ASD Level 1. SpringerLink
- Genova, H. M., et al. (2023). Development and adaptation of a strength-based job interview intervention (KF-STRIDE). Frontiers
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