Mental Health Treatment in Autism: Evidence and Limitations

Mental health problems are common in autistic people, including anxiety and depression. This article reviews current evidence on psychological treatments and outlines important limitations in real-world practice.

Mental health problems are common in autistic people. They are not secondary issues.

Around 20% of autistic individuals experience depression and 11% experience anxiety. These rates are higher than in the general population.

Among autistic females, the numbers are higher again. About 77% receive at least one psychiatric diagnosis by age 25.

What Treatments Are Currently Used

Cognitive Behavioral Therapy (CBT) is the main psychological treatment used for anxiety and depression. This is also true for autistic people.

There is good evidence that CBT can be effective when it is adapted.

In children aged 6 to 13, adapted CBT has shown large effect sizes. One randomized trial found an effect size of 1.7, which is considered large. In this model, sessions were longer (90 minutes) and included parents.

In adults, both CBT and Mindfulness-Based Stress Reduction (MBSR) have been shown to reduce anxiety and depression. Some evidence suggests that MBSR may work better for people who have high baseline distress or more rigid thinking patterns.

Overall, this suggests that psychological therapy can work in autism, but it doesn’t play out as cleanly in practice.

Other Therapeutic Approaches

CBT is the most studied psychological treatment in autism, and therefore is frequently discussed, but it is not the only approach that can be helpful.

Other therapeutic models are used in practice and may be more appropriate for some individuals, depending on their needs and preferences.

Mindfulness-based approaches, including Mindfulness-Based Stress Reduction (MBSR), have shown evidence for reducing anxiety and depression in autistic adults.

These approaches focus less on changing thoughts and more on observing internal experiences and reducing reactivity.

Acceptance and Commitment Therapy (ACT) is another related approach. It emphasizes psychological flexibility, values-based action, and acceptance of internal experiences rather than direct cognitive restructuring.

This may be useful for individuals who find traditional cognitive approaches difficult or unhelpful.

Compassion-focused therapy (CFT) may also be relevant, particularly for individuals with high levels of self-criticism or shame.

In addition, some individuals may benefit from more supportive or relational approaches, including therapies that focus on identity, lived experience, and meaning-making rather than symptom reduction alone.

There is currently less research on these approaches in autistic populations compared to CBT.

The Problem: Outcomes Are Worse in Practice

Results from controlled studies do not fully match what happens in the therapy room.

A large study of primary care psychological therapy services in England found that autistic adults did show reductions in symptoms during treatment.

However, compared to non-autistic adults, they were:

- less likely to show reliable improvement

- less likely to recover

- more likely to deteriorate .

This is important, because it means that while therapy is not failing completely, it is not working as well as it should.

This gap suggests that current approaches are still not well matched to autistic people.

Why Standard Cognitive Behavioral Therapy Does Not Fit Well

Standard CBT is based on certain assumptions:

- that people can identify and describe their emotions

- that thoughts can be easily accessed and changed

- that distress is mainly driven by internal cognitive processes

These assumptions are not always valid in autism. Many autistic people experience alexithymia (difficulty identifying and describing emotions).

If a person cannot clearly identify what they feel, then standard cognitive restructuring becomes difficult.

In addition, distress in autism is often linked to external factors, like:

- sensory overload

- social misunderstanding

- lack of support

- pressure to mask autistic traits

This means that focusing only on internal thoughts is often not sufficient.

What Adapted CBT Looks Like

1. More Structure and More Time

Standard therapy sessions are usually around 50–60 minutes. Some adapted approaches use longer sessions, often around 90 minutes.

There is also more emphasis on structure, including:

- clear agendas

- predictable session format

- advance explanation of tasks

Modular approaches are also used, meaning that therapy is divided into distinct modules (exposure, cognitive restructuring) vs using a standardized protocol.

2. Less Reliance on Verbal Cognitive Work

Many autistic people find abstract verbal reasoning difficult, especially related to emotions.

Adapted therapy often shifts away from purely cognitive techniques and includes:

- behavioral strategies (such as exposure and behavioral activation)

- visual supports

- concrete examples

Visualization can be used throughout therapy to make abstract ideas more understandable. For example, utilizing social stories, emotion charts, visual diagrams, and visual schedules.

3. Addressing Alexithymia Directly

Alexithymia should be addressed directly in therapy.

If someone cannot identify their emotions, then asking them to challenge thoughts about those emotions is unlikely to work.

Effective approaches include:

- teaching recognition of bodily sensations

- linking physical sensations to emotions

- focusing on behavior when insight is limited

Emotion regulation can still improve with adapted CBT, even when alexithymia is present.

4. Consider the Environment

Distress in autism is often linked to the environment.

Therapy should address external factors such as:

- sensory sensitivities

- social demands

- lack of predictability

Simple changes can help, like adjusting lighting, reducing noise, and allowing alternative communication methods.

Providing written summaries or extra processing time can also improve outcomes.

5. Addressing Camouflaging

Camouflaging refers to masking autistic traits in order to fit in, and is associated with anxiety, depression, and burnout.

Adapted CBT does not appear to increase camouflaging. In some cases, it decreases as anxiety improves.

Therapy should:

- discuss masking and its costs

- focus on reducing anxiety rather than changing identity

- support authentic self-expression

6.Adjusting Treatment Goals

Standard therapy often focuses on symptom reduction.

In autism, it may be more useful to focus on:

- quality of life

- autonomy

- person–environment fit

While symptom reduction may still be an effect of this, it is not the only goal.

What This Means for Clinicians

The evidence shows that therapy can work for autistic people. However, standard approaches are not sufficient.

Adaptations include:

- changing session structure

- modifying communication methods

- adjusting therapeutic techniques

- addressing environmental factors

- reconsidering treatment goals

The aim is to reduce distress and improve functioning in a way that is consistent with the person’s identity.

References

- El Baou, C., et al. (2023). The Lancet Psychiatry.

- Wood, J. J., et al. (2020). JAMA Psychiatry.

- Cooper, K., et al. (2018). Research in Autism Spectrum Disorders.

- Linden, A., et al. (2023). Autism.

- Loizou, S., et al. (2024). BJPsych Open.

- Spain, D., & Happé, F. (2019).

- Rodgers, J., et al. (2024). Journal of Autism and Developmental Disorders.