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Jessica Kitchens on the Clinical Needs of Autistic Adults
Filed Under: Cognitive-Behavioral (CBT), Person-Centered, Addiction, Anxiety, Autism, Bipolar Disorder, Depression
In This Interview…
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Lawrence Rubin: I’m here today with Jessica Kitchens, who describes herself as a conscious, inclusive, Indigenous and artistic leader dedicated to enhancing the lives of others through collaborative efforts. She also describes herself as Autistic, Indigenous, wife, mother of five, CEO, therapist, consultant, author, trainer, board certified cognitive specialist, addiction specialist and neuro diversity advocate. And of course, she is a clinician. Hi Jessica, thanks for joining me.
Jessica Kitchens: Glad to be here, Lawrence.
LR: Let’s begin with terms. What is a late identified Autistic?
JK: Late identified Autistics are individuals that have been Autistic their whole lives but may not have been recognized as such because they have developed high masking capabilities. They decided that it was better for them to adapt certain behavioral patterns in order to fit in. It is something they have come to do automatically. They don’t know why; they just knew that they needed to. Later on in life, they recognized that this method of fitting into social norms, while self-protective, also came with a high cost. They begin to struggle as the demands of adulthood kick in, so to speak. Sometimes, they become aware of the burden of masking their own struggles when their child is diagnosed.
LR:
late identified Autistics are individuals that have been Autistic their whole lives but may not have been recognized as such because they have developed high masking capabilities
The ability to recognize and then mask difficulties seems to be an advanced coping skill, but a very demanding, and perhaps tiring one. Do they reach a tipping or breaking point? JK: Absolutely! There’s a lot of wear and tear that goes into high masking because of the psychological and emotional energy expenditure. Many of these individuals cope with masking by abusing substances or through process/behavioral addictions like gambling, shopping, and gaming, to name a few. That’s sometimes why they end up coming to see me, unless they are referred by family members or their employers or school personnel suggest it. But others simply burn out or shut down.
LR: I imagine they may also present with anxiety, depression, and/or substance abuse. But I can also see a therapist missing the Autism if they either don’t look for it or are not trained to look for or assess it.
JK: Absolutely. There are a lot of misdiagnosed individuals out there walking around with a higher proportion of them being female, but there are high masking males out there as well. These individuals may be diagnosed with bipolar disorder because the dysregulation can come out sometimes as mania, or they present symptoms of borderline personality disorder. I was personally misdiagnosed with generalized anxiety disorder.
LR:
these individuals may be diagnosed with bipolar disorder because the dysregulation can come out sometimes as mania, or they present symptoms of borderline personality disorder
What are some of the reasons that a clinician, especially one that is non-Autistic, might miss the Autism diagnosis? JK: Unfortunately, this is a common problem. We have a lot of professionals out there that are really good at what they do, but they have not had adequate or up-to-date training on what Autism now looks like, because they’re still looking at very old stereotypes. It wasn’t even in the DSM until 1980, and even then, they still had a very distorted view of what it was.
It’s only now that Autistic researchers are coming out and talking about their own lived experience and we’re finally changing what the diagnosis looks like because there’s a lot of what I would call iceberg Autistics out there. They’ve masked for so long and kept a lot of this stuff underneath. Therefore, a lot of clinicians are over-relying on stereotypes and media representations of lower functioning, higher support needed individuals like Rain Man.
They miss the diagnosis of Autism when they see someone like me, thinking something like, “you don’t you don’t look like my cousin who has Autism. So unfortunately, there are a lot of clinicians out there that are doing some harm because they do not have up-to-date training.
It’s only now that Autistic researchers are coming out and talking about their own lived experience and we’re finally changing what the diagnosis looks like because there’s a lot of what I would call iceberg Autistics out there. They’ve masked for so long and kept a lot of this stuff underneath. Therefore, a lot of clinicians are over-relying on stereotypes and media representations of lower functioning, higher support needed individuals like Rain Man.
They miss the diagnosis of Autism when they see someone like me, thinking something like, “you don’t you don’t look like my cousin who has Autism. So unfortunately, there are a lot of clinicians out there that are doing some harm because they do not have up-to-date training.
LR:
there are a lot of clinicians out there that are doing some harm because they do not have up-to-date training
So up to date training would tell clinicians that Autism is far more, or far different than being able to count 496 matches on the floor, stimming, self-harming, or having real difficulties making eye contact, to name some of the more familiar symptom clusters. What are the new generation of trained clinicians looking for? JK: A lot of times, these clients come in because of dysregulation, even though they may not use the term. They may find themselves easily dysregulated in their work environment or in their home environment. They may actually have a visceral, nervous system response to sounds and lights. And since Autism is a dynamic disability, they may struggle in their relationships because of difficulties with pragmatic communication. On a given day, these folks, me included, may have difficulty finding the simplest of words to use. When a clinician is trained to look for these subtleties, they are in a better position to ask the right questions.
LR: Are there benefits of first being diagnosed in adulthood?
JK: That’s a good question and one that a lot of them must decide for themselves. A formal diagnosis in certain settings, like school or work, can help them get accommodations, such as adaptations to the sensory environments, that can put them on par to where they can now be equal and function at a baseline level with some of their neurotypical peers. Sometimes they can get them without a formal diagnosis, but some work environments are exceedingly difficult in allowing that. And sadly, we still have a lot of ableism in work environments.
For others not necessarily pursuing accommodations, formal diagnosis can empower them to re-consider their dysregulation, learn coping mechanisms such as mindfulness, and review their life in a way that now makes sense to them.
For others not necessarily pursuing accommodations, formal diagnosis can empower them to re-consider their dysregulation, learn coping mechanisms such as mindfulness, and review their life in a way that now makes sense to them.
LR:
sadly, we still have a lot of ableism in work environments
Wouldn’t we the want the newly diagnosed adult to be referred to a clinician who knows how to help this particular client? JK: Absolutely, but unfortunately, there are clinicians out there that can do more harm than good if they don't have the right knowledge to work with these clients. I’m very picky about who I work with because there’s a lot of nuances that go with the neurodiversity affirming framework, such as learning about the nervous system functioning of an Autistic adult.
LR: Have you seen any downsides to a person being diagnosed in adulthood with Autism?
JK: Within work environments, there are instances of ableism among managers or supervisors who work against accommodations. The problem can be institutional.
LR: So just as there are institutional racism and institutional homophobia, there is also institutional ableism?
JK: It’s heavy and it’s ingrained in all aspects of our culture. One of the things that I’m working on in my PhD research is decolonizing ableism by utilizing and looking at indigenous perspectives of Autism through my own and other tribes. I’m trying to view it through an indigenous and a decolonizing framework, because the Western medicine is entrenched with a lot of deficit-oriented stereotypes. It’s everywhere. It’s in our schools, it’s in our work, it’s in medical institutions. We do have capabilities. We want people to recognize that we are autonomous persons, and just because we struggle with certain skills, there are many things that we are still capable of, and many Autistic adults are quite gifted in many ways.
LR: How has being a late diagnosed Autistic influenced your professional trajectory and shaped who you are in the therapy room with clients?
JK: It’s changed everything. I was formally diagnosed a few years ago, but it was my youngest daughter of my five that was diagnosed before any of us, and now my youngest three are all formally diagnosed with ADHD and Autism. It’s one of those things that’s literally changed every facet of my life. Every conversation that I have with people is entrenched in this.
The ways I review my childhood and how I view my future are now entrenched with this view which has also affected my research and PhD journey. I don’t ever see it going back. I’ve had to grieve a lot of my life, but there is no me without Autism because this is who I am. It explains so much. It explains all the things that I’ve probably struggled with my whole life.
The ways I review my childhood and how I view my future are now entrenched with this view which has also affected my research and PhD journey. I don’t ever see it going back. I’ve had to grieve a lot of my life, but there is no me without Autism because this is who I am. It explains so much. It explains all the things that I’ve probably struggled with my whole life.
LR: In the case of an Autistic adult, what is neurodiversity affirming intervention?
JK: A person-centered orientation seems to be the best for most of these clients. But knowledge and the understanding of certain Autism experiences like pathological demand avoidance or rejection sensitive dysphoria, goes a long way. So does using correct terms such as identity first language—using the word ‘Autistic,’ rather than ‘a person with Autism.’
LR:
a person-centered orientation seems to be the best for most of these clients
What do you mean by saying that a person-centered approach is best? JK: Meeting them where they’re at – a lot of times clinicians have this view that they need to fix people. That’s not what it is. You know? It’s more about matching that congruence and recognizing that you we are capable of so much beyond the narrow limits of what the diagnosis suggests. It’s about recognizing what skills can actually help us be the best that we can be as a person, whatever that looks like. Whether it’s mindfulness, EMDR, or CBT. It’s about grabbing from modalities of all types. Everybody’s different.
It’s not about coming from a place of judgment. I don’t want to push my views on my client of what I think they need to be working on. I want them to have an idea of areas they want to grow in and using whatever tools and skills I have to help them get there.
It’s not about coming from a place of judgment. I don’t want to push my views on my client of what I think they need to be working on. I want them to have an idea of areas they want to grow in and using whatever tools and skills I have to help them get there.
LR:
there is this misconception that people are being overly diagnosed, that we’re handing it out like candy
Are there myths and misconceptions that clinicians bring into this work that hinders intervention?JK: There is this misconception that people are being overly diagnosed, that we’re handing it out like candy. Clinicians who believe this go in with automatic blinders. In reality, Autism goes back generations in families, so a new diagnosis should not be that surprising or unlikely. And because these adults are bringing their children in for diagnosis, it makes sense to either formally or informally assess and perhaps even help that parent. And while it’s not a myth or misconception per se, internalized ableism on the part of the client or clinician, or both, can hinder the intervention process.
LR: Have you encountered resistance from some clients who are on the doorstep of the diagnosis?
JK: The only resistance that I’ve noted has not come from the clients themselves. It has been from their families because a lot of them take it as an affront to who they are or believe in some way that they caused it. And so again, that goes back to some internalized ableism. Sometimes, these clients come to me already knowing about the possibility. A lot of them actually did. Sometimes, it comes to them after I’ve planted seeds.
LR:
the undiagnosed or unaware Autistic clinician is going to miss it in their clients if they’ve missed it in themselves
Is an undiagnosed Autistic therapist a potential risk to either neurotypical or neurodiverse clients? Or is the therapy potentially limited by a clinician who is unaware of – or resistant to – acknowledging their Autism? JK: The undiagnosed or unaware Autistic clinician is going to miss it in their clients if they’ve missed it in themselves. I’ve been there too. I have to look back and reckon with the fact that there are some clients with whom I’ve missed important aspects of their experience because I wasn’t thinking about the possibility of Autism.
LR: We know that stress increases as life demands accelerate, so are older teens and young who have not yet been diagnosed at a greater risk?
JK: It’s interesting that you ask that question because I was a co-researcher on a Delphi study on what independent living looks like to Autistic adults. And as far as moving out on their own or going to college or working, many of these young people start struggling all of a sudden, or at least far more than they had previously.
They did well at home and well in school because there was a lot of structure and stability. But now all of the sudden they’re required to function on a higher level. Logistics are a different monster altogether such as paying bills and adapting to new, and complex sensory and demand environments.
They did well at home and well in school because there was a lot of structure and stability. But now all of the sudden they’re required to function on a higher level. Logistics are a different monster altogether such as paying bills and adapting to new, and complex sensory and demand environments.
LR: Is the diagnostic threshold different for teens than it is for adults?
JK: I would expect the clinician to be able to identify high masking, and to use multiple sources in the assessment of younger clients who may not be able to report fully. I think it’s often harder to diagnose a child because they can’t speak for themselves. If the clinician uses appropriate measures and asks the right questions, it can actually be easier because they can ask about the internal processes, not just your behaviors and what you do and what others see, but what the internal processes are.
LR: Can you think of a few assessment instruments off the top of your head?
JK: The Social Responsiveness Scale is one that was done on me. I felt like, man, that asked a lot of the right questions, and there was also a Sensory Profile that really nailed it, at least for me.
LR:
many people on the spectrum actually have higher than average affective empathy
What are some of the relationship and family issues that Autistic adult clients bring to you? JK: There is an interesting challenge for Autistic adults called the double empathy problem. One of the stereotypes is that these people lack empathy, which is the furthest thing from the truth. Many people on the spectrum actually have higher than average affective empathy. The disconnect comes from alexithymia, meaning they may not be able to label that feeling, but they can feel it. A lot of them do struggle with Theory of Mind (ToM), also known as cognitive empathy. That’s the problem with necessarily putting yourself in the shoes of the individual and understanding their perspective.
So, you might have two individuals with high affective empathy, but differences in their cognitive empathy. The double empathy problem manifests in, one or the other member of the couple or family member, not feeling understood. They might butt heads, which then leads to a lack of reciprocity. That’s one of those nuances that a non-neurodiversity affirming therapist might miss.
So, you might have two individuals with high affective empathy, but differences in their cognitive empathy. The double empathy problem manifests in, one or the other member of the couple or family member, not feeling understood. They might butt heads, which then leads to a lack of reciprocity. That’s one of those nuances that a non-neurodiversity affirming therapist might miss.
LR: What might be some of the challenges to Autistic parents?
JK: Parents also struggle with the double empathy problem. Some of the biggest communication struggles I had with my teen children were whenever we were coming from different places of reciprocity or understanding each other’s perspectives.
LR: What is internalized ableism?
JK: As a parent, it could be expecting an Autistic child to do something a non-Autistic child can do or expecting a partner to somehow be or act normally, without respecting their diversity and difficulties. That child or adult then internalizes that prejudice and may struggle unnecessarily, beating themselves up, instead of accepting certain limitations and learning effective coping skills.
LR: You identify as indigenous, and work with indigenous clients? Does Autism manifest differently among indigenous people?
JK: Absolutely. Here in Arkansas, I don’t have as many clients as I would if I was back in Oklahoma 20 years ago, which is where my tribe is, the Potawatomi. And we know the Māori in New Zealand have a word for Autism called Takiwãtanga, which means in your own time and place. They have a more positive frame of mind for Autistics.
LR:
many Autistics have high affective empathy, and deep sense of justice
We tend to pathologize differences, but I am now wondering about some of the unique skills and advantages associated with Autism, perhaps that a clinician could capitalize on. JK: I feel like it’s different for everybody, but many Autistics have high affective empathy, and deep sense of justice. A lot of us are really hard-core advocates in general because of our empathy. It tears us up whenever somebody is being mistreated. Other than that, the noting of patterns. For me, it’s behavioral patterns. I was able to learn behavioral patterns early on to mask my differences, but it can also help me to note incongruences with my clients. We can also be quite analytic. Clearly, we have many broad capabilities, so stereotypes often simply fall short.
LR: Finally, what are some resources and organizations that clinicians can use to improve their identification and intervention skills?
JK: If you’re going to work with Autistics, you need to know about pathological demand avoidance, also known as persistent drive for autonomy, which is PPDA. PPDA North America is a useful resource for this, but there’s also NeuroClastic, which I believe is a 501 C3. They work the business side; working with businesses and hiring Autistic individuals and they do a lot of good. There’s also the Autistic Self-Advocacy Network.
LR: Is there anything I failed to mention, Jessica, or questions I could have asked?
JK: There are so many nuances to appreciate about this population, and it is so much more than reading the DSM when you work with these clients. You’re going to learn the most from individuals with lived experience and those who have entrenched themselves into Autistic research.
LR: On that note, Jessica, thank you so very much for your expertise and sharing your valuable time.
JK: No problem. I really appreciate it.
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Jessica Kitchens, LPC, RPT, is a therapist who operates Kitchens Counseling Services, where she specializes in substance use, play therapy, and is a Board-Certified Cognitive Specialist. She has lived experience as a late-diagnosed autistic with a PDA profile, and a mother of five children (ages 10-24), several of which are diagnosed with AuDHD, and the youngest with PDA as well. Jessica also has an MBA and is currently pursuing a PhD in Change Leadership for Equity and Inclusion with an emphasis on Community Leadership and Change. Jessica, her husband of 25 years, and her children have called NW Arkansas home for almost 20 years. In her spare time, she likes to write and research areas of interest, spend time in nature, run, skate, work out, dabble in art on occasion, and spend time with her friends, and family. Jessica has a strong love for working with neurodivergent individuals and hopes to make a brighter future for those in her community. Her website is Home - Jessica Kitchens.
Jessica Kitchens was compensated for his/her/their contribution. None of his/her/their books or additional offerings are required for any of the Psychotherapy.net content. Should such materials be references, it is as an additional resource.
Psychotherapy.net defines ineligible companies as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with ineligible companies. We ask that all contributors disclose any and all financial relationships they have with any ineligible companies whether the individual views them as relevant to the education or not.
Additionally, there is no commercial support for this activity. None of the planners or any employee at Psychotherapy.net who has worked on this educational activity has relevant financial relationship(s) to disclose with ineligible companies.
Lawrence ‘Larry’ Rubin, PhD, ABPP, is a Florida licensed psychologist, and registered play therapist. He currently teaches in the doctoral program in Psychology at Nova Southeastern University and retired Professor of Counselor Education at St. Thomas University. A board-certified diplomate in clinical child and adolescent psychology, he has published numerous book chapters and edited volumes in psychotherapy and popular culture including the Handbook of Medical Play Therapy and Child Life: Interventions in Clinical and Medical Settings and Diagnosis and Treatment Planning Skills: A Popular Culture Casebook Approach. Larry is the editor at Psychotherapy.net.
Lawrence Rubin was compensated for his/her/their contribution. None of his/her/their books or additional offerings are required for any of the Psychotherapy.net content. Should such materials be references, it is as an additional resource.
Psychotherapy.net defines ineligible companies as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with ineligible companies. We ask that all contributors disclose any and all financial relationships they have with any ineligible companies whether the individual views them as relevant to the education or not.
Additionally, there is no commercial support for this activity. None of the planners or any employee at Psychotherapy.net who has worked on this educational activity has relevant financial relationship(s) to disclose with ineligible companies.