“Oh, you couldn’t be autistic”: Examining anti-autistic bias and self-esteem in the therapeutic alliance

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Darazsdi, Z. & Bialka, C. S. (2023). “Oh, you couldn’t be autistic”: Examining anti-autistic bias and self-esteem in the therapeutic alliance. Autism, 27(7), 2124-2134. https://doi.org/10.1177/13623613231154622

Publication date: 19 Feb 2023 Added to AutiHub: 10 Oct 2026 Type: Article Article language: English
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Authors

Publication authors
2
Publication authors identified as autistic
1 / 2 (50.0%)
  1. Zoe Darazsdi *
  2. Christa S. Bialka

Abstract

Presently, most mental health practitioners in the United States are educated, trained, and employed in a system focused on curing or changing autistic people. As a result, mental health practitioners may exhibit anti-autistic bias—any form of bias that degrades, devalues, or others autistic people or traits —when engaged with autistic clients. Since the collaborative relationship between therapist and client, termed the “therapeutic alliance,” is often viewed as the most influential element of therapeutic effectiveness, our phenomenological study examined 14 autistic adults’ experiences with anti-autistic bias in the therapeutic alliance and the relationship they perceive it has on their self-esteem. Findings, determined through thematic analysis, reveal implicit, unintentional bias was manifested through clinical assumptions about autism, explicit, overt bias was expressed through feelings of intentional harm, and repair of self-esteem was shown through positive alliances. Based on the findings of this study, we offer recommendations to help mental health practitioners and mental health practitioner training programs better serve autistic clients. This study addresses a significant gap in current research on anti-autistic bias in the mental health field and the overall well-being of autistic individuals. Lay Abstract Many mental health practitioners in the United States are trained to cure or change autistic people. Some of these mental health practitioners may show anti-autistic bias when working with autistic clients. Anti-autistic bias is any kind of bias that degrades, devalues, or others autistic people or autistic traits. Anti-autistic bias is especially problematic when mental health practitioners and clients are engaged in the therapeutic alliance, which is the collaborative relationship between a therapist and client. The therapeutic alliance is one of most important parts of an effective therapeutic relationship. Our interview-based study examined 14 autistic adults’ experiences with anti-autistic bias in the therapeutic alliance and the relationship they felt it has on their self-esteem. Results from this research showed that some mental health practitioners expressed hidden and unrealized bias when working with autistic clients, such as making assumptions about what it means to be autistic. Results also showed that some mental health practitioners were intentionally biased and openly harmful to their autistic clients. Both forms of bias negatively affected participant self-esteem. Based on the findings of this study, we offer recommendations to help mental health practitioners and mental health practitioner training programs better serve autistic clients. This study addresses a significant gap in current research on anti-autistic bias in the mental health field and the overall well-being of autistic individuals.

Bibliography cited by this reference

Cited references are imported from external metadata sources when they are available. The list may be partial.

Cited bibliography overview

These indicators describe the bibliography cited by this publication. An author name is counted each time it appears in one cited reference, so the same person can be counted more than once. Names not yet linked to an author already present in AutiHub are treated as unknown, not as non-autistic. Last computed: 23 Oct 2026 08:00.

Cited references
50
With a DOI
40
Without a DOI, from raw bibliography text
7
6 / 50 (12.0%) cited references include at least one author identified as autistic.
References with data to complete
6 / 50 (12.0%)
References with detected author names
46 / 50 (92.0%)
Without detected author names
4
Without a structured title
6
Without a stable identifier
7
References with raw author names still to review
4
References with external metadata lookup issues
1
These indicators apply to cited references displayed on this page, after technical duplicates have been merged. A reference without a DOI can still support author statistics when a title and author names are available.
Author names detected in the cited bibliography
115
From DOI or external metadata
115
From validated raw bibliography text
0
Raw names already validated
0
Raw names still to review
4
47 / 115 (40.9%) names are linked to an author already present in AutiHub. 68 / 115 (59.1%) names are not yet linked.
Names linked to a person identified as autistic
7 / 115 (6.1%)
Calculated across all author names detected in the cited bibliography. Among names linked to an author already present in AutiHub: 7 / 47 (14.9%). Distinct people identified as autistic: 7 / 112 (6.2%).
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