April is World Autism Month, a time to raise awareness about the autism community and build inclusive spaces for all types of autistic clients. We asked Christine Molina, LCSW, to help us understand more about how to notice and support autistic clients with EMDR therapy.

The Unseen Spectrum: EMDR with High-Masking Autistic Clients

Guest Blog Post by Christine Molina, LCSW 

As clinicians, we are trained to look for certain signs of autism. Difficulty with eye contact. Obvious sensory reactions. Struggles with basic social interaction. However, in recent years, research has discovered that autism is much more varied than people once thought (Henderson et al., 2023). Many autistic individuals are articulate. They may be socially skilled. And they are often successful in many ways. 

That does not mean that autistic individuals do not experience struggles. Research shows that 79 percent of autistic adults meet the criteria for mental health conditions (Lever & Geurts, 2016) and many seek out therapy. In fact, one study in Sweden found that 18.9 percent of adults who seek mental health treatment are autistic, with another 5-10 percent having subthreshold symptoms; yet, surprisingly, only 5.3 percent of them are diagnosed (Nyrenius et al., 2022). Looking at these stats, it appears that many of us are working with autistic clients and may not even know it. 

The cost of masking

Masking, or camouflaging, refers to strategies that autistic individuals use to hide autistic traits or appear “neurotypical” so they can fit into society.  This may include forcing eye contact, scripting conversations in advance, or suppressing intense interests. 

This ongoing effort to mask is exhausting. And, over time, it takes a toll. Research links high-masking behaviors to higher rates of anxiety, depression and suicidality (Cage & Troxell-Whitman, 2019). Unfortunately, many autistic adults never get a diagnosis (Nyrenius et al., 2022) and without an explanation for why they feel different, they often attribute their struggles to a character flaw instead of a difference in brain wiring. 

For EMDR therapists, it is important to recognize the subtle presentations of autism. Perfectionism may be hiding underlying executive functioning challenges. Social anxiety could be caused by the pressure to mask. Substance use might stem from trying to reduce emotional overload. 

When we miss high-masking autism, we risk missing the underlying reasons for our clients’ suffering and the chance to support them in the ways that they need. 

Spotting the signs of high-masking autism

Autism is a neurodevelopmental condition, with differences in social relationships and social communication, as well as restricted and repetitive behaviors and interests (American Psychiatric Association, 2022). 

While this clinical definition gives us a starting point, it doesn’t capture the experiences of high-maskers. According to Henderson et al. (2023), these clients tend to exhibit much subtler presentations of autism. Here are some of the signs you might see: 

  • Social Communication: High-masking individuals can be quite social. They can make eye contact, ask follow-up questions, and laugh at the right moments. But this is frequently the result of intense conscious effort. Hull et al. (2017) describe how autistic adults learn to adjust their tone, mimic gestures, and follow carefully studied rules for social interaction. They are carefully analyzing social interactions so they can act the “right way.” 
  • Repetitive Movements: The stereotypical image of autism includes head-banging or hand-flapping. But high-maskers often exhibit repetitive movements (called stims) in subtler ways. They may pace, twirl their hair, or watch the same movie over and over. These behaviors help autistic individuals self-soothe and regulate. 
  • Routines and Inflexibility: This may not look like rigid behavioral routines or challenges. Instead, you may notice perfectionism, rigid rule following, black-and-white thinking, or anxiety related to unexpected change. 
  • Special Interests: Not every autistic person is obsessively interested in trains or prime numbers. Many high-maskers are deeply passionate about things that look perfectly ordinary from the outside, like K-Pop, a TV universe, or makeup. The intensity of the interest is the tell, not the subject matter. 
  • Sensory Sensitivities: High-maskers may endure sensory discomfort in silence, pretending not to notice loud noises or enduring fluorescent lighting. 
  • Empathy: There is a common myth that autistic people lack empathy. But in reality, many autistics have an imbalance in empathy. They may feel other people’s emotions deeply, sometimes overwhelmingly (affective empathy), but require more effort to infer others’ intentions (cognitive empathy). 

Trauma and autism

Autistic individuals are more likely to experience daily events as traumatic and report higher rates of trauma than their non-autistic peers. Research by Weiss and Fardella (2018) shows that autistic adults are 27.1 times more likely to report being bullied or teased and 7.3 times more likely to endorse sexual assault by a peer.  

They also experience a unique kind of trauma. The trauma of living in a world that is not designed for your brain. Oftentimes, they have had a lifetime of being corrected, misunderstood, excluded, or exhausted, creating deep feelings of shame and anxiety. 

EMDR therapy can be transformative for these individuals. But, as with any other population in therapy, we need to tailor our approach to support their needs and experiences. 

EMDR therapy with high-masking autistic clients

I first started working with high-masking autistic clients in 2014. What was surprising to me was that they seemed to have more trouble with the standard EMDR protocol than my ADHD (Attention Deficit Hyperactivity Disorder) clients. Sometimes, it was hard to get all the components of memory in a target. Others had difficulty tolerating dual attention stimulus (DAS). Often, our work did not generalize as well.  

To address these challenges, I relied on what I knew about autism and began to experiment. As it turns out, I was not the only one doing this. In 2022, two journal articles came out examining the experiences EMDR therapists had with autistic clients (Fisher et al., 2022; Van Diest et al., 2022). Their findings reflected many of the things I discovered in my own practice. Here is what we have learned. 

Flexibility is essential

Every autistic client is different. Some clients need minimal changes to the standard protocol; others require much more. A good general principle is to follow the standard protocol and then skip or change something if it is not working. Your clients will be your best guide for what works. 

Prioritize self-understanding

Helping clients learn about autism can be profoundly healing. And it is often a vital, ongoing part of therapy. 

At first, this may include screening for autistic traits. And over time, it may involve exploring with clients how their brain functions, why certain situations feel challenging, and what their sensory and relational needs are. This knowledge empowers clients to develop strategies that work for them and significantly reduces feelings of anxiety and shame. 

Focus on strengths

Autistic brains come with incredible strengths: exceptional attention to detail, an intuitive grasp of how things work, deep and sustaining passions, creative problem-solving, strong internal motivation, and so much more. Their ways of perceiving the world have led to extraordinary contributions in many fields. 

In therapy, guide clients to uncover and embrace their strengths. This is often an effective way to build confidence, self-compassion, and lasting change.  

Support communication needs 

Autistic and non-autistic people use different parts of the brain during social interactions and often have different communication preferences. Learn about your client’s communication style so you can develop strategies to support them. Here are some things you can try: 

  • Use Prompts: For some clients, open-ended questions can be hard to answer, leading to anxiety, yes/no answers or “I don’t know.” If this happens, help clients find words for their experience by using closed or forced-choice questions, a menu of options, or visual tools (e.g. feeling charts, rating scales). 
  • Allow More Time: Autistic clients may process information at a slower rate and in a detail-focused way. They may need more time to respond to questions. 
  • Be Clear and Direct: Clients may have trouble inferring your intentions and knowing what to expect. Clearly explain what will happen in therapy and why it is important. 
  • Check for Overwhelm: Clients’ internal experiences may not always match the nonverbals you see. Watch for subtle signs of distress and ask if they are feeling overwhelmed. 
  • Concretize Abstract Concepts: Emotions, social dynamics and internal states can feel abstract for some clients. You can make these concepts more tangible by using metaphors and physical representations (e.g. visual tools, drawings, and objects). 

Phase specific modifications

Preparation (Phase 2) 

  • Preparation and Stabilization: Some clients can begin the standard protocol with minimal modifications; while others need more time to establish a safe therapeutic relationship, develop skills for identifying emotions, and build the capacity to manage emotions and sensory distress.  
  • EMDR Mechanics: Many clients can use the standard forms of dual attention stimulus (DAS), such as eye movements, tones, tapping. However, some with sensory sensitivities may need other ways to tax working memory and facilitate processing. These could include movement, music, or self-soothing stims. 
  • Safe Place: With clients who experience aphantasia (difficulty visualizing), it can be helpful to use external representations like drawings, photos of real locations, objects in the room, or activities tied to their passions. 

Assessment (Phase 3) 

If clients struggle to identify components of memory in phase 3, adapt by using only a few elements at first. If needed, you can also use visual aids (feeling charts, visual rating scales) or offer examples rather than open-ended questions. If they have trouble visualizing an image, substitute it with another sensory experience (sounds, smells) or a different component of memory (emotions, body sensations). 

Reprocessing (Phase 4 to 6) 

Autistic brains process information in a detail-focused way and may not transfer information from one context to another (a concept called weak central coherence). This means that clients might not automatically generalize gains from one memory to related experiences. 

You may need to process more targets than you might with non-autistic clients and explicitly make connections between past experiences and present-day challenges. 

Some final thoughts

I am grateful that we, and our society, are starting to realize how common autism is. It often looks different from the stereotypes. Many clients are undiagnosed. For this reason, it is a good idea to screen for autism. Many individuals report that learning about autism is the missing piece that finally allows them to be themselves and thrive. 

EMDR therapy can be a powerful modality for these clients. However, you may need to make adaptations. Ask lots of questions, be flexible, and let your clients teach you. 

If you want to learn more, I encourage you to dive in. Seek out consultation, take trainings on autism, and explore the explosion of resources that have popped up in recent years. Your efforts will pay off. And you will be surprised how much better your clients respond to therapy when they can finally feel seen, understood and celebrated for the unique and wonderful ways that their brains work. 

 

Christine Molina, LCSW is an EMDRIA Approved Consultant™ in Austin, TX, specializing in EMDR therapy, neurodiversity, attachment and trauma. She facilitates at EMDR basic trainings and teaches EMDR trainings on autism and complex trauma. She integrates EMDR with relational, parts and somatic modalities to help clients heal and love their brain. 

 

References 

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), 5(5). https://doi.org/10.1176/appi.books.9780890425787  

‌Cage, E., & Troxell-Whitman, Z. (2019). Understanding the reasons, contexts and costs of camouflaging for autistic adults. Journal of Autism and Developmental Disorders, 49(5), 1899–1911. https://doi.org/10.1007/s10803-018-03878-x  

‌Fisher, N., Patel, H., Van Diest, C., & Spain, D. (2022). Using eye movement desensitisation and reprocessing (EMDR) with autistic individuals: A qualitative interview study with EMDR therapists. Psychology and Psychotherapy Theory Research and Practice, 95(4), 1071–1089. https://doi.org/10.1111/papt.12419  

Henderson, D., Wayland, S., & White, J. (2023). Is This Autism?  Taylor & Francis. 

Hull, L., Petrides, K. V., Allison, C., Smith, P., Baron-Cohen, S., Lai, M.-C., & Mandy, W. (2017). “Putting on my best normal”: Social camouflaging in adults with autism spectrum conditions. Journal of Autism and Developmental Disorders, 47(8), 2519–2534. https://doi.org/10.1007/s10803-017-3166-5  

‌Lever, A. G., & Geurts, H. M. (2016). Psychiatric co-occurring symptoms and disorders in young, middle-aged, and older adults with autism spectrum disorder. Journal of Autism and Developmental Disorders, 46(6), 1916–1930. https://doi.org/10.1007/s10803-016-2722-8 

Molina, C. (2024, November 8 and December 13). EMDR and “Subtle” presentations of adult autism: What every clinician should know [Webinar]. National presentation for ComplexTraumaInc, USA, Online 

‌Nyrenius, J., Eberhard, J., Ghaziuddin, M., Gillberg, C., & Billstedt, E. (2022). Prevalence of autism spectrum disorders in adult outpatient psychiatry. Journal of Autism and Developmental Disorders, 52(9), 3769–3779. https://doi.org/10.1007/s10803-021-05411-z 

Van Diest, C., Leoni, M., Fisher, N., & Spain, D. (2022). Using EMDR with autistic clients: How do therapists adapt? Journal of EMDR Practice and Research, 16(3), 123–134. https://doi.org/10.1891/emdr-2022-0014  

‌Weiss, J. A., & Fardella, M. A. (2018). Victimization and perpetration experiences of adults with autism. Frontiers in Psychiatry, 9(203). https://doi.org/10.3389/fpsyt.2018.00203  

 

 

Back to Focal Point Blog Homepage

 

Additional Resources

If you are a therapist interested in the EMDR training:

If you are EMDR trained:

If you are an EMDRIA™ Member:

 

Basic Info Collapse

Date
April 10, 2026

Contributor(s)
Christine Molina, LCSW 

Topics
ADHD/Autism/Neurodiversity

Practice & Methods
Neurobiology

More Info Collapse

Audience
EMDR Therapists

Language
English

Content Type
Blog/Blog Post

Access Type
Open Access

Related Articles