This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of working with adults and knowledge of autism, as well as a supervision framework. It replaces neither your clinical judgement nor your professional responsibility, and it does not make you competent to diagnose autism if you have not been trained to do so. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself. It is not written for the people concerned: if you are asking yourself the question, start with the guide Am I autistic? ADHD in adulthood. And if you are thinking about dying, contact your country's emergency services or a helpline today.
1. The programme at a glance
Indication. An autistic adult, without intellectual disability and with functional spoken language, diagnosed or undergoing assessment, who seeks help for suffering: anxiety, low mood, exhaustion, overload crises, difficulties at work, in studies or in relationships, or a need to understand and integrate a recent diagnosis.
Reference model. Structured post-diagnostic support, and cognitive behavioural therapy adapted to autism in line with the adaptations recommended by NICE (CG142) and described in the literature: more concrete, more explicit, more visual, at an adjusted pace, and built on the person's interests. The model of understanding is that of a lasting gap between the demands of the environment and the person's resources, made worse by sensory load, uncertainty and the cost of camouflaging.
Format. Fourteen individual sessions of 50 to 60 minutes, weekly up to session 9, then fortnightly. Two booster sessions, at one month and at three months. Same day, same time, same room as far as possible: predictability is part of the protocol. A written summary is handed over or sent after each session.
Mechanism targeted. Reducing the load, not changing the person. In practice: lowering sensory, social and uncertainty costs; making energy and its limits visible; treating anxiety and mood with proven, adapted methods; and giving the person the means to obtain adjustments and to make themselves understood.
| Session |
Focus |
Session output |
| 1 |
Welcome, framework and status of the diagnosis |
Written framework, safety checked, baseline measures |
| 2 |
The formulation |
Written profile: strengths, difficulties, costs |
| 3 |
The sensory profile |
Sensory map, three dated adjustments |
| 4 |
Energy and recovery |
Record set up, one load removed |
| 5 |
Camouflaging |
Inventory, one mask-free space chosen |
| 6 |
Anxiety: understanding |
Worries sorted, two targets rated |
| 7 |
Anxiety: experimenting |
Two experiments done, one change prepared |
| 8 |
Emotions and overload |
Body thermometer, overload plan |
| 9 |
Mood and activities |
Three activities brought back, one load removed |
| 10 |
Explicit communication |
Personal user guide, ready-made sentences |
| 11 |
Work or studies |
Written adjustments, decision on disclosure |
| 12 |
Relationships |
Relationship map, one step taken |
| 13 |
Preventing crises and burnout |
Written plan in three levels |
| 14 |
Review, plan and what comes next |
Measures repeated, plan for what comes next |
What the person takes away. Nine printable worksheets, listed in section 43: my profile, my senses, my energy, my camouflaging, my worries, my thermometer, my requests, my prevention plan, and a worksheet for those close to me and my employer.
What distinguishes this programme from the other manuals on this site. Three things. It does not treat a disorder that is expected to disappear: autism stays, and what changes are the living conditions and the associated disorders. It starts with the environment — sensory load, energy, adjustments — before asking the person to change anything at all. And it gives an explicit place to two notions that the classifications touch on lightly or ignore, but which organise the lives of many autistic adults: camouflaging and autistic burnout.
2. Before you begin
Who this programme is for
This text is written for psychologists, psychiatrists, neuropsychologists, psychotherapists and doctors who work with adults, who are trained in cognitive behavioural therapy, and who have a basic knowledge of autism. It assumes that you know how to assess suicide risk, recognise depression and work with a doctor.
It is written neither for autistic people nor for those close to them. It contains elements of differential diagnosis, risk and non-response that are put differently when speaking to the person concerned. The guide Am I autistic? ADHD in adulthood is written for them, and the site offers an orientation questionnaire that only says whether an assessment is indicated.
The four preliminary decisions
Where does the diagnostic question stand? Diagnosis made, assessment under way, question not yet explored, or self-identification without assessment: these four situations are not handled in the same way. Section 4.
Is there current suicide risk? It is markedly higher in autistic adults than in the general population, it is often poorly detected, and it is looked for with direct, literal questions. Section 11.
Is there established burnout? A person in severe burnout does not have the resources for exposure work or change work. You then start by reducing demands. Section 34.
What does the person want to change, and what do they not want to change? The question seems trivial. It is decisive in this indication, because many autistic adults have already received interventions aimed at correcting what they had not asked to have corrected. Section 16.
What this programme does not treat
It does not make a diagnosis. It describes the pathway, the tools and the limits, and it tells you when to refer. Section 8.
It is not written for autistic adults with an intellectual disability or without functional spoken language. Their support requires other tools, other modes of communication, and a larger role for those around them and for health and social care teams. Section 39.
It does not, on its own, treat severe depression, a psychotic disorder, a serious eating disorder or catatonia. These are treated with their own protocol and, most often, with a doctor. Sections 9 and 10.
It does not aim to teach the person to "appear" non-autistic. If the person asks for work on social skills, it is done on their own goals — getting a job, making friends, negotiating an adjustment — not on a norm.
How to use it
Read the whole text before the first session, in particular sections 3, 6, 8, 11, 17 and 33: the position, the model, the assessment pathway, safety, the framework and the adaptations of therapy. These are the six places where the support succeeds or fails.
Each session is described with the same structure: the aim, the steps, what you say, common mistakes, and the criterion for moving on.
Three warnings specific to this indication.
You are one of the possible sources of difficulty. An implicit instruction, a change of time announced the day before, a noisy waiting room, a buzzing fluorescent light, a vague question: what seems trivial to you can cost a whole session. The framework in section 17 is not a courtesy, it is a condition of the work.
Observed behaviour does not tell you what the person feels. A face with little expression, a gaze that does not settle, a very brief answer or a laugh at the wrong moment tell you nothing about mood, alliance or interest. Ask.
And fatigue is not resistance. A task not done, a cancelled session, a silence: in many autistic adults, it is first a question of energy, and that is the first hypothesis to check.
3. A position: neurodiversity, and the evidence
What the neurodiversity movement says, and what it has brought
The central idea is that autism is a different, lasting way of perceiving, processing information and relating to others, and not an illness to be cured. It was carried first by autistic people, then taken up and discussed in research (Kapp et al., 2013; Pellicano and den Houting, 2022).
It has brought the clinician three things. Attention to what the people concerned actually ask for, which is almost never to become someone else. Attention to the costs of forced adaptation, in particular of camouflaging. And a reading of communication as a two-way problem: when two people who function differently misunderstand each other, the difficulty does not lie entirely with one of them. This is what Milton (2012) called the double empathy problem, and experimental work points in the same direction: information was passed on as well between autistic people as between non-autistic people, and less well in mixed groups (Crompton et al., 2020).
What the evidence also says
Autistic people have anxiety, depression and sleep disorders more often than the general population (Lai et al., 2019); in adults, anxiety and depression each affect more than one person in three over the lifetime (Hollocks et al., 2019), and suicidal ideation is much more common than in the general population (Cassidy et al., 2014). In a large Swedish cohort, mortality among autistic people was higher, and the risk of death by suicide markedly increased, even more so among those without intellectual disability (Hirvikoski et al., 2016). Access to employment is difficult: among young autistic adults who had left secondary school, competitive employment was rare, and those without intellectual disability were more often without any daytime activity at all (Taylor and Seltzer, 2011). Part of these difficulties comes from the environment — misunderstanding, discrimination, unsuitable sensory and social demands — and the minority stress model partly accounts for it (Botha and Frost, 2020). Another part comes from difficulties of the person's own, which do not disappear when the environment changes.
The position of this manual
The aim is to reduce suffering and costs, not to make the person neurotypical. No goal of the programme concerns eye contact, the suppression of harmless repetitive movements, the disappearance of an interest or an appearance of normality.
What can be treated is treated. Depression, an anxiety disorder, insomnia or suicide risk are not "autistic traits" to be respected: they are disorders that have treatments, and autistic adults are entitled to them like everyone else, with the necessary adaptations. Giving up on treating them in the name of acceptance would be a professional failing.
The difficulties are not denied. A respectful position does not consist in saying that everything is fine. It consists in acknowledging what is costly, looking first for what can be changed in the environment, and leaving the person the choice of what they want to work on in themselves.
The evidence applies in both directions. An intervention is not good because it is presented as respectful, nor bad because it comes from a behavioural tradition. Several practices widely recommended by autistic communities — reducing camouflaging, organising recovery, preventing burnout — are consistent with the available evidence but have not been evaluated in trials. This manual proposes them, and it says that they are not proven. Section 13.
Vocabulary
This manual writes "autistic person" and "autistic adult". In a large British survey, the term "autistic" was chosen by a large share of autistic adults, but by far fewer professionals, nearly half of whom chose "person with autism"; no wording was unanimous (Kenny et al., 2016). Ask the person what they prefer, and use their words. The same principle applies to "autism spectrum disorder", "autism", or the older term "Asperger's", which some people diagnosed under that name continue to use: it is their identity, not your classification.
4. Four entry situations not to be confused
1. The diagnosis has been made
What you observe. A report exists, recent or old. The person seeks help for something else: anxiety, exhaustion, difficulty at work, conflict in the couple, or a need to understand what this diagnosis changes.
What points the way. Read the report. It tells you how the diagnosis was made, with which tools, which childhood sources, which differential, and which co-occurring conditions were or were not identified.
What it implies. This is the main situation of this programme. An old diagnosis made in childhood, or a very brief one, may justify updating the profile, not systematically calling it into question.
2. Assessment is under way or has been requested
What you observe. A referral has been made, an appointment is awaited — often for many long months.
What points the way. Current suffering does not wait for the diagnosis.
What it implies. You treat what can be treated — anxiety, mood, sleep, exhaustion — adapting the way you work to the profile observed, and you help prepare for the assessment. Section 8.
3. The question arises and has not been explored
What you observe. The person, someone close to them or you yourself are wondering whether they are autistic.
What points the way. A long-standing cluster of features, present since childhood, in several domains, with an impact, and not better explained by something else. Section 9.
What it implies. You do not have to decide alone. You carry out an initial screening, you examine the other hypotheses, and you refer if the cluster justifies it. The site's orientation questionnaire can help the person see where they stand; it makes no diagnosis.
4. Self-identification, without assessment
What you observe. The person says they are autistic, has had no formal assessment, and does not always want one — for lack of access, because of cost, for fear of being turned down, or because they do not see the point.
What points the way. Two questions: what they expect from a diagnosis, and what the absence of a diagnosis prevents them from obtaining.
What it implies. You can work on the profile they describe — sensory issues, energy, communication — without either validating or contesting the label. You say honestly what an assessment would bring — access to certain rights, examination of differential diagnoses — and you do not make it compulsory before starting. What you do not do: write a document suggesting that a diagnosis has been made.
The three sorting questions
"Has anyone ever assessed you for this, and what did they conclude?" It places the person among the four situations.
"What costs you the most today?" It brings things back to current suffering, which is the indication for the programme, whatever the status of the diagnosis.
"What has been offered to you so far, and what helped you or harmed you?" It identifies previous care that was badly experienced, which is common and weighs on the alliance.
5. The clinical picture in adults
What people describe
They rarely describe "social communication difficulties". They describe an effort: the feeling of having learned social rules like a foreign language, of having to calculate what seems natural to others, of coming home exhausted from an ordinary day.
The sentences that come back: "I've always felt I was playing a part", "I don't understand what's expected of me until someone tells me", "after a meeting, I need the whole evening to recover", "I can't stand the noise of people", "everyone thinks I'm doing fine, and I'm at the end of my tether". This last one is often the most important.
The two domains, as they present in adulthood
Communication and social interaction. Reciprocity that requires conscious effort: knowing when to speak, for how long, on what topic, how to keep things going. A slower or less intuitive reading of implicit signals — hints, irony, facial expressions, tone, unspoken expectations. A different use of gaze, gestures and prosody. Relationships that are often few, sometimes very deep, and difficulty understanding the codes of friendships, romantic relationships or working relationships when they are not made explicit.
Behaviours, interests and sensory experience. Routines and ways of doing things that reassure, and whose modification is costly, even when the change is pleasant. Intense, lasting interests, often a source of competence and pleasure. Repeated movements or handling of objects, often discreet in adults, which soothe or help concentration. And a particular sensory experience: sounds, lights, textures and smells perceived too strongly — or too weakly —, sometimes with a dampened perception of hunger, pain, temperature or fatigue.
Sensory experience, central and underestimated
It is often what weighs most in daily life, and it is what people mention least spontaneously, because they have always lived this way and think that everyone endures the same thing. Sensory differences are common in autism (Ben-Sasson et al., 2009), and they have been part of the criteria since DSM-5.
What to remember in practice: a large part of these adults' exhaustion and anxiety is sensory before it is social. An open-plan office, a supermarket or a noisy family meal cost more through noise and light than through the people. Session 3.
Special interests
They are not symptoms to be reduced. In autistic adults who have them, they are associated with better subjective well-being and greater satisfaction, particularly in social contact and leisure; only engagement of very high intensity is associated with lower well-being (Grove et al., 2018). They are often the main source of recovery, and they are a first-rate therapeutic lever: an example taken from the person's area of interest is remembered where a generic example is not. Section 33.
What can be a problem is not the interest, but what it costs elsewhere: sleep sacrificed, obligations forgotten, spending. This is dealt with like any other question of organisation, without devaluing the interest.
What changes in women, and in people who camouflage
Identification long relied on male, visible presentations. Many women — and some men — develop effective compensation strategies early on: observing, imitating, preparing conversations, learning rules. They go unnoticed, and they pay for it (Lai et al., 2017; Bargiela et al., 2016). Interests are sometimes less atypical in their subject than in their intensity — people, animals, psychology, literature —, which makes them less noticeable.
Among children who meet the criteria, the male-to-female ratio is closer to three to one than to the four to one often assumed; it is higher in studies that only count diagnoses already made, which suggests an identification bias to the detriment of girls (Loomes et al., 2017).
Strengths
They exist and they are named — but the person's own, not those of a stereotype. Attention to detail, memory for facts, perseverance, frankness, loyalty, a sense of justice, in-depth knowledge of a field: none is guaranteed, and pinning on a list of "typical" qualities is as reductive as pinning on a list of deficits. Ask the person what they do well, and look for evidence in their life.
What autism in adults is not
It is neither an absence of empathy — what differs is the intuitive reading of signals, not concern for others —, nor a lack of interest in relationships, nor an acquired disorder, nor the effect of upbringing: the hypotheses that claimed so have been abandoned, and they still weigh on families. And it is not rare: prevalence studies published worldwide, mostly in children, give a median of about one person in a hundred, with large variations according to region, context and method (Zeidan et al., 2022).