Towards Neurodiversity-Affirming,Co-Produced Competence Frameworks in Psychotherapy: An Autistic-Led Call to Action

Dear editor,

Our central concern is that competence frameworks in psychotherapy are developed without the explicit involvement of people with lived experience. When clinical guidance is positioned as universally applicable (Wade & Waller, 2025), the absence of lived experience perspectives has implications for safety, inclusivity, and real-world applicability (Davis et al., 2024). Experiential knowledge offers critical insights into how clinical practices are experienced by clients, including where well-intentioned interventions may result in unintended iatrogenic harm (Honkalampi et al., 2025). Increasingly, mental health research recognises co-production not only as good practice but also as an ethical safeguard when interventions are applied across heterogeneous populations (Davis et al., 2024). Given their role in shaping norms of practice, researchers and academic journals have a responsibility to embed iatrogenesis prevention, epistemic humility, and lived experience involvement within competence frameworks that are framed as broadly applicable.

In addition, mental health research rarely acknowledges the possibility of iatrogenic harm in psychotherapy (Honkalampi et al., 2025). There is ample evidence demonstrating that psychological interventions can result in iatrogenesis, particularly when power dynamics and intersectional factors are insufficiently considered (Cobbaert, 2026). For autistic people, potential harms include pressure to conform to neuronormative expectations, blanket misinterpretation of contextually adaptive coping strategies as inherent pathology, and invalidation or dismissal of sensory, cognitive, or communication support needs (Flower et al., 2025; Lewis & Stevens, 2023). Psycho-behavioural frameworks would be strengthened by explicitly acknowledging these risks and offering guidance on how to mitigate them (Cobbaert, 2026).

Several commonly promoted clinical competencies warrant caution when applied generically (Wade & Waller, 2025). Directive or standardised approaches to empathy and engagement may be helpful for some clients but can become problematic when they rely on implicit neurotypical assumptions about how trust, alliance, and emotional safety are established. For many autistic people, meaningful therapeutic engagement depends on relational conditions that support psychological and epistemic safety, including being believed, not having to perform neurotypical reciprocity, and having differences understood rather than interpreted as resistance or deficit (Flower et al., 2025). Emerging qualitative and empirical research suggests that trust, validation of lived experience, and collaborative pacing are often prerequisites for engagement rather than outcomes of therapy (Brewe et al., 2021). In their absence, apparent engagement or compliance may instead reflect masking, appeasement, or attempts to meet perceived clinician expectations rather than authentic participation. Competence frameworks intended for broad application should therefore foreground relational safety and flexibility, recognising that alliance formation may not follow neurotypical assumptions about interpersonal processes.

Competence frameworks that prioritise early change and measurable improvement also warrant careful scrutiny when applied generically (Wade & Waller, 2025). Although early behavioural shifts or symptom reduction are often interpreted as indicators of therapeutic progress within standard psychotherapy models, such changes do not necessarily reflect genuine improvements in wellbeing for autistic clients. Apparent improvement may instead reflect masking, compliance, appeasement, or efforts to align with perceived therapeutic expectations, particularly when clients feel the pressure to demonstrate progress within predetermined treatment trajectories or models shaped by neurotypical assumptions about recovery (Flower et al., 2025). Observable short-term changes may therefore obscure whether therapeutic gains are authentic, sustainable, internally experienced as beneficial, or achieved at the expense of psychological and relational safety. Prioritising rapid improvement without sufficient contextualisation also risks reinforcing power asymmetries within therapy, where clinician-defined indicators of success are privileged over client-defined experiences of wellbeing and capacity. Greater emphasis on collaborative pacing, client-defined goals, and shared interpretation of change is therefore needed to avoid conflating externally observable behavioural change with meaningful and sustainable wellbeing.

Similarly, routine outcome monitoring assumes that commonly used psychometric instruments validly and reliably capture distress, functioning, and therapeutic progress across populations. However, many widely used measures were not developed or validated for autistic people, raising concerns regarding construct validity, interpretive accuracy, and the risk of diagnostic overshadowing (Nicolaidis et al., 2020). Such measures may insufficiently capture autistic experiences of distress, wellbeing, and therapeutic change, particularly where sensory processing differences, masking, communication differences, and divergent experiences of emotional expression shape how distress is recognised, conceptualised, or communicated (Pavlopoulou et al., 2025). Differences related to alexithymia and interoception may further complicate how internal states are identified or reported.

Consequently, standardised scores may not straightforwardly reflect lived experiences of improvement or deterioration. For example, increases in reported distress may reflect therapeutically meaningful processes such as unmasking, increased emotional awareness, enhanced self-recognition of unmet needs, or trauma processing rather than clinical worsening. Conversely, unchanged or reduced scores do not necessarily indicate lack of benefit or genuine recovery, particularly where clients minimise distress, mask difficulties, or adapt responses to align with perceived therapeutic expectations. Without collaborative and context-sensitive interpretation (Flower et al., 2025), routine outcome monitoring risks narrowing clinical attention to what is easily measurable while reinforcing neurotypical assumptions about functioning, communication, and recovery. This may inadvertently privilege externally observable symptom change over client-defined experiences of safety, authenticity, self-understanding, and sustainable wellbeing. We therefore recommend supplementing standardised measures with accessible and collaboratively interpreted narrative check-ins, using concrete prompts such as “What felt easier or harder this week?” or “Did anything feel more manageable, overwhelming, or different recently?” Such approaches may better support communication differences and allow autistic clients to describe meaningful changes in wellbeing that may not align with conventional symptom descriptors or normative recovery trajectories. Flexible and multimedia response options, including visual supports, iPad-based communication apps, voice recordings, written responses, or creative formats such as collage or poetry, may further enhance accessibility and reduce the risk of communicative misattunement within therapeutic assessment processes.

These concerns are particularly relevant in relation to exposure-based approaches, where generic assumptions about distress, avoidance, and therapeutic benefit may insufficiently account for autistic sensory and cognitive experiences. While exposure can be helpful for some individuals, distress experienced by autistic people is often linked to sensory processing differences, executive functioning difficulties, and systemic oppression rather than “distorted” cognitions or “irrational” fears (Pavlopoulou et al., 2025). In such circumstances, repeated exposure to overwhelming stimuli may intensify distress and cause sensory and/or cognitive overload, increasing the risk of shutdown, burnout, or psychological trauma (Lewis & Stevens, 2023). Competence frameworks intended for broad application should therefore distinguish between different sources and narratives of distress and avoid assumptions of universal suitability.

Although many psychotherapy frameworks encourage adapting protocols to the individual, guidance on adaptation is often underspecified. In practice, adaptation is frequently operationalised as minor adjustments to language or session structure while leaving core assumptions about goals, mechanisms of change, and indicators of progress unexamined. For autistic people, meaningful adaptation often requires deeper collaboration, including jointly redefining therapeutic goals; renegotiating pacing based on sensory, executive function, and cognitive processing needs rather than session number or symptom trajectories; and explicitly discussing what relational safety, progress, and wellbeing mean for the individual. Care individualisation is further supported by providing clients with explicit and ongoing opportunities to offer feedback on therapeutic strategies, allowing clinicians to adjust collaboratively and avoid persisting with misattuned interventions. We also recommend the use of curious, non-assumptive exploration, for example, through questions such as “Does this idea fit with your experience?”, which positions clients as epistemic authorities on their own lived experiences and reduces the risk of interpretive overreach. Without clearer guidance on these deeper forms of adaptation, psycho-behavioural frameworks risk privileging procedural fidelity over relational safety and epistemic responsiveness, particularly for individuals whose needs diverge from neuronormativity.

Our intention is not to dismiss the value of psychotherapies, nor to suggest that autistic people cannot benefit from them. Rather, we argue that competence frameworks positioned as generic should explicitly incorporate harm prevention, epistemic humility, and lived experience involvement. This includes recognising lived experience as a form of expertise in its own right, attending to power and positionality within therapy, and acknowledging that improvement may take diverse and non-linear forms (Pavlopoulou et al., 2025).

We therefore call for greater investment in co-produced and neurodiversity-affirming mental health research, including trials and implementation studies that meaningfully involve lived experience experts from design through dissemination. Psychotherapy competence frameworks should be evaluated not only on their internal coherence but also on their ethical grounding, validity across populations, risks of iatrogenic harm, and translational value. Beyond research contexts, neurodiversity-affirming and co-produced competencies should be more explicitly embedded within psychotherapy training curricula, practicum supervision, competency evaluations, professional accreditation frameworks, and continuing professional development initiatives. Such efforts should focus not on positioning clinicians as autism specialists, but on strengthening epistemic humility, relational responsiveness, collaborative adaptation, and harm-prevention competencies across therapeutic settings. Journals, funders, training institutions, and professional bodies all have a critical role to play in setting these expectations.

As mental health research and practice continue to engage with questions of accessibility, safety, and inclusion, it is essential that widely disseminated clinical frameworks do not inadvertently reinforce neuronormative assumptions or contribute to avoidable harm (Flower et al., 2025). Greater engagement with lived experience scholarship, alongside the meaningful involvement of autistic people as co-designers in research and as epistemic partners within the therapeutic alliance itself, would strengthen the ethical grounding, scientific validity, and translational value of competence-based approaches to psychotherapy, increasing the likelihood that observed treatment effects reflect genuine and sustainable wellbeing for autistic individuals.