by Clinical Psychologist, Dr Hugh Walker (6th December, 2024)
Section 1: Society, Difference, Camouflaging and the Critic
Camouflaging and masking as a compensatory mechanism to being different.
Camouflaging or masking refers to the process where autistic individuals mimic socially successful behaviours, suppressing their autistic traits to appear socially competent (Attwood, 2006). This often leads to internal confusion, anxiety, and overwhelm (Cook, Hull, Crane, & Mandy, 2021). Fombonne (2020) wrote that camouflaging should not be understood as an intrinsic aspect of autism (i.e. a brand-new subtype) though represents one of many compensatory strategies observed in autistic populations.
The links between compensatory strategies that neurodiverse children and adolescents deploy once they become more aware of their difference (Attwood, 2006, p. 27) and the overlap with the Coping Modes or Parts of Schema Therapy has been a fascinating are of inquiry over the past few years. It is my belief that these developmental psychotherapy models such as Schema Therapy (herein ST, Brockman et al., 2023) and Internal Family Systems Therapy (herein IFS, Schwartz, 2020) can assist many of our clients with more refined case conceptualisations and psychotherapeutic approaches to a range of problems, including those categorised as Autistic Burnout, Rejection Sensitive Dysphoria, and Pathological Demand Avoidance as well as just general types of anxiety and depressive symptoms. I referenced some aspects of this in my last blog and my colleagues and I published Schema Therapy for Autistic Adults: Scoping Review (Vuijk, Turner, Zimmerman, Walker, & Dandachi-FitzGerald, 2024). In this blog I expand on the approach specifically in regards to Autistic Burnout. Due to the enormity of the topic, there is a level of assumed knowledge in the areas of Schema Therapy and neurodevelopmental conditions and the audience is directed towards clinicians and clients who may already have some understanding of ST or IFS.
Where Impression Management turns pathological: Society and the Inner Critic.
Erving Goffman (1956) highlighted how individuals attempt to control or guide the impression that others might make of them by changing or fixing his or her setting, appearance, and manner. Indeed, most individuals will engage in a level of impression management which involve a level of masking or over-compensation to form a favourable impression and achieve a goal (e.g. a job interview). The intensity and prolonged durations of conscious though often unconscious masking by autistic children and adolescents, starting at a young age that we talk of in this article is significantly more insidious and pervasive. Unfortunately, there have been good historical reasons for young children absorbing from societal messages about difference as defective that motivates desires to act in inauthentic ways given the history of how autistic people have been institutionalised, bullied or excluded for their differences. The repeated neurotypical expectations and adverse events that send the message that one must “appear normal” in school, work and social contexts can lead to the development of these messages to be internalised in the form of one’s self-talk, which in Schema Therapy terms is called a Critic (or inner critic).
Historical accounts of a psychological inner critic in psychotherapy
The idea of a young child internalising a moral standard based on parental guidance, cultural norms and social expectations can be traced as far back to Freud’s “super-ego”, which was one of three parts of his personality structure (1923). Klein’s object relations theory (1946) progressed this concept again positing that the centrality of early relationships of the self with others become internalised echoes of the past (also known as introjections) that feed into patterns of private self-talk. She called these representations “objects”, and many found the framework useful to understand and treat psychological issues rooted in early trauma, attachment disruptions, or deep-seated relational pattern. From my point of view these early theories have laid the groundwork for Jeffry Young’s Parent Modes (Young, 1990) which has been appropriately modernised to Critic Modes to reflect contributions from siblings, peers, teachers, coaches and society more generally in the formation of one’s inner critic (Brockman et al. 2023). As a researcher interested in the mechanisms of how psychotherapy works, it is interesting to note that several contemporary externalise and concretise this inner voice such as: the internal voice (Ellis, 1962), a manager part in IFS (Schwartz, 1995); the mind or the thinking self in ACT (Hayes, Strosahl & Wilson, 1999), the definitions of splitting and projection of an internal judge onto the other (Fredrickson, 2020), as well as others. Models that look to help the client become more consciously aware of, and then shift metacognitive processes have been extremely helpful to easing psychological suffering. Once externalised clients are better able to unblend (Schwartz, 2020) or defuse (Hayes et al., 1999) from aspects of negative self-talk to identify the function and reinforcement history of listening to the content of the thought and then practise meeting the function while converting the content from one that is punitive, demanding or guilt-inducing to one that is compassionate and balanced (Brockman et al., 2023).
An evolutionary lens of the critic’s adaptive functions: Attachments, connection, and survival.
Why does it seem that in mental health, all roads lead to the critic (Brockman et al., 2023)? What is the function of this mechanism and how did the process evolve..? I would posit that the critic acts as a powerful software program evolved over thousands of years to absorb societal messages and morals during early childhood experiences that tries to solve the problem of maximising the child’s chance at maintaining connection to attachments and society when born into any family in any given culture at any epoch across time. Moreover, while the process of the program doesn’t change, the contents of the messages change according to family of origin, culture, and which century the child finds themselves born into.
Like many complex systems within ecology, biology, and psychological flexibility there are trade-offs between overregulating and under regulating actions and a solution is found within maintaining a constant dialectic pressure. This is emphasised in psychotherapies of ACT and DBT of doing what is workable whether that be accepting and letting go of struggle of a particular aspect of the present moment or seeking for change towards a particular aspect of the moment (Linehan, 1993, Hayes et al., 1999). Perhaps the inner critic mechanism evolved from a dialectic pressure of ensuring a community is not over-governing behaviour too powerfully so as to cause maladaptive levels of shame, guilt, anxiety, and sadness (e.g. a bad thought is analagous to a bad action) to its children while not undergoverning behaviour too softly that would lead to behaviours deemed unacceptable to flourish unchecked (e.g. stealing, lying, harming others).
In this way, the critic’s function acts as a cultural transmission mechanism where the child has internalised norms of the microcosm of the family and the macrocosm of society carry on in adaptive ways given that context (cf. functional contextualism, Biglan & Hayes, 1996). The assumption that it would be adaptive to maintain predictions in childhood from the family of origin may have made sense thousands of years ago with little means of transport available to relocate during our adult years. The process thereby ensures communities remain cohesive and that these children grow into parents who filter to the next generation of children, hopefully values around care and understanding with appropriate levels of limit-setting and boundaries to shape undesirable behaviours. One can also imagine the utility of this cultural transmission mechanism when a society was overrun following war and annexed under new rulers, and it would have been adaptive for the next generation to quickly adapt and conform to the new norms else be punished or exiled with death a real possibility in both cases.
Moving our analysis of the critic mechanism to some of its problems is the idea that across time is what if society gets it wrong and attributes an immutable non-modifiable aspect of a person as something to be criticised, shamed and over-regulated. Then we can have people who have no hope of living up to the societal expectations shamed for their difference, internalising an inner critic that incessantly punishes, demands and guilt-trips them in a vicious cycle that leads to forms of over-compensation, avoidance, and burnout. Examples in my lifetime when societal norms have been critical of immutable and non-modifiable aspects of the self-include natal sex, sexual orientation, skin tone, mobility, learning difficulties, among others (Meyer, 2003; Cardoso, Lima, Costa, Loose, Liu, & Fabris, 2024). With regard to the non-modifiable aspects of information processing in neurodiverse groups such as autism and ADHD (in which these processing differences can appear to be invisible to the uninformed parent, teacher, clinician, or society member). The more invisible the difference, the more likely that societal members will unintentionally demand neurotypical standards onto the child, adolescent or adult such as mandatory use of eye-contact in social interactions or the assumption that education can only take place when the student is still, seated and facing the front. In this case, the person who may be unaware of their neurodiversity and has potentially been peppered with neurotypical standards, the critic mechanism is dialling up over years to more demanding, punitive, and guilt-inducing levels which, when listened to (i.e. “What’s wrong with you, looking at your teacher when they are talking to you), and acted upon (i.e. forces eye-contact with teacher and disconnects from emotional experience to perform the critic’s request), and reinforced (i.e. Techer smiles or praises [positive reinforcement of compensation] or teacher at least does not criticise [negative reinforcement of compensation].
Similarly, what if society believes aspects of a person’s behaviour that are in truth modifiable are seen as immutable and need to be accepted and under-regulated (i.e. a nurturance trap or conflation of modifiable psychological symptoms incorrectly formulated as non-modifiable). This also runs the risk of issues whereby reduced guidance, support, scaffolding and reasonable boundaries are given to support development and growth within an acceptable window of affect tolerance or “zone of proximal development” (Vygotsky, 1978).
Returning to analysing how the critic evolves in the first scenario of society expecting change of an individual members non-modifiable trait, while in the moment listening to the critic might have been perceived to be the solution for the individual because listening to the inner critic takes away distress and receiving praise (or avoids shaming) from the authority figure, in the long-term reinforcement of the inner critic’s neurotypical expectations which I have been labeling with Autistic clients who experience repeated cycles of burnout as a Neurotypical Critic. As an example of this in a chair work session to build mode awareness, a client siting in the chair of the neurotypical critic anxiously exclaimed towards another chair with a photo of their 6-year-old self on the seat (representing their neurodivergent vulnerable child mode), “I am constantly begging you to at least act like a normal functioning adult but you can’t even do that”, “your life is painful to witness”, “I’ve been saying this for decades; You just keep trying and you keep failing”. Returning to the seat of the child we processed the impact of these incessant introjections. At the neurobiological level, I am interested in the links between these introjections, the stress response, and the immune response and the depressive and burnout symptomology that follows and plan to write my next blog on this topic. These introjections perpetually rally through the mind minute-to-minute, before and after social interactions and with the application of relational frame theory (Barnes-Holmes, Y., Hayes, S. C., Barnes-Holmes, D., & Roche, B., 2002), it’s easy to see how the critic begins to expand more and more derived relations such that before too long, the critic reacts to a range of distal antecedents that end up driving pathological levels of rumination, over-compensation and avoidance increasing psychological inflexibility and negatively impacting psychological well-being which drive the burnout cycle.
Fortunately, the critic and maladaptive aspects of self-organisation are modifiable with psychotherapy (Artnz, 2022). In writing this article it was interesting to listen to and read other researchers and clinicians have come to similar conclusions proposing an ableist critic in the STAND Attuned Model of Schema Therapy for neurodivergent clients (DeCicco, Garrett, Smith, Clarkson, & Ambrosius 2023) characterised by internalised ableist expectations on the neurodivergent person. Similarly, Cardoso and colleagues (2024) who described an “inner critic (oppressive sociocultural) mode characterised by the internalisation of prejudice against sexual and gender diversity, comprising of schemas, emotional states, and coping strategies that develop in response to the oppressive environment”. This transdiagnostic application of schema therapy is certainly an exciting space to watch and I look forward to reading and contributing to further case series and pilot trials of these approaches for these minority groups in our community. For any researchers reading this, our clinic is always interested in collaborating with regard to research trials.
Relevance to positive aspects of the Neuroaffirming movement
If the individual learns from society that these normative expectations as the only acceptable way to be in the world, and that way is incompatible with who they are, significant internalised mental health issues such as anxiety and depression are likely to follow, and this may be why certain minority groups experience a higher prevalence of mental ill-health than others. With respect to autistic camouflaging and masking the hypothesis would be that a great deal of the compensation and masking is driven by an internalised neurotypical critic blended into the individual’s self-talk, hiding in plain sight of their everyday thought stream. This is where the developments in my lifetime of a society that is more aware of mental health and neurodiversity affirming of different ways to be in society can have a flow-on effect to soften the punitiveness and demanding nature of the next generation of children’s socio-normative inner critic.
It is interesting when reviewing current literature about the neuroaffirming paradigm and its origins (Pantazakos & Vanaken, 2023; Cherwick & Mategria, 2023) that it is rare to read a citation acknowledging Professor Tony Attwood’s pioneering education for professionals and parents (1998). I place Tony’s seminal publications as one of the paradigm shift epicentre with regular national and international trainings during the early 2000s to packed conferences which led to new generations of parents, health professionals and educational professionals applying this understanding of what we now call neuroaffirming principles at home, clinics and schools. One hypothesis for why Tony’s contribution to the strengths based and neuroaffirming approach may have been lost to the history books at this time could be that his publications reference Asperger’s which from 2013 with the latest DSM-5 (APA, 2013) was subsumed into the autism-spectrum, Nonetheless, I think Tony is deserving of more recognition as a vital pioneer in the space who also one of the first to elevate the voices of other autistic elders and mentors.
Relevance to Early Discovery of Diagnosis.
Furthermore, this is why early diagnosis and strengths-based education about one’s neurodiversity is critical to not only inform the child and developing a positive self-concept though to inform parents, teachers and other societal members who might not be perceptive of neurodiverse differences to be more aware and accommodate to suit. If societal norms adapt to increase awareness and knowledge of neurodiversity and careful differentiation of modifiable and non-modifiable factors for the individual then the negative feedback loop on the individual’s internalised critic to become more demanding, punitive and guilt-inducing to fit-in to an unworkable neurotypical standard can reverse which should have powerful positive impacts on well-being for neurodiverse people.
Section 2: Autistic Camouflaging.
Camouflaging and Masking: The first accounts.
I first learned about camouflaging from my mentor, Professor Tony Attwood (2006, p. 27), who described it as “imitation,” based on his clinical observations and research into autobiographical accounts from autistic women (Williams, 1998, p. 73; Willey, 1999, p. 23). At this time the central focus was on ensuring that clinicians assessing clients were not blindly following the ADOS-2 results and really delivering a holistic assessment looking out for the possibility that features of A1, A2, A3 (DSM-5, 2013) could be performed within the 1-2 hour consultation though to look for evidence of fatigue and if there was anxiety and depression to be formulating the causal pathways of this distress given the client’s superficially good social skills.
I would describe traits of masking as actions such as avoiding places were socialising takes place, avoiding asking questions to fly under the radar or on the group’s periphery, avoiding offering authentic responses just the minimal niceties to not raise too much suspicion or attention, suppressing repetitive behaviours, detaching from discomfort cues related to sensory overwhelm, utilising numbing and distracting substances to assist detachment). Camouflaging behaviours include studying the verbal and non-verbal communication and interests of socially successful peers and mimicking them, asking frequent open-ended questions to keep the person interested and talking, in all social situations always acting based on the rules of needing to be the most helpful and polite person, often talking about what others want to talk about and sometimes pretending to like or dislike things for the sake of group cohesion). While some exploratory factor analysis studies have proposed a 3-factor model (Hull et al., 2019) of Camouflaging, our clinical experience at M&H would suggest it might make sense to simplify this into two factors: Overcompensation and Masking and subsuming aspects of Assimilation into these two categories.
The involvement of Self-Understanding and Identity Disturbance.
Individuals presenting at the clinic frequently exhibit considerable confusion about their identity, as well as a lack of self-understanding and coherence concerning their likes and dislikes. This may be attributed to the necessity of concealing their authentic needs (i.e. interoceptive cues and feelings), even from themselves (Fredrickson, 2020), due to a subconscious prediction that revealing their neurodiverse traits could potentially lead to social rejection or rupture in their relationships (i.e. state-based alexithymia). In other cases, the difficulty of understanding one’s authentic needs (via interoceptive cues) can be due to a lack of scaffolding and guidance of understanding emotional information as is common in autistic clients (i.e. trait-based alexithymia).
In the development of one’s sense of self, imagine thousands of iterations of not knowing and/or disavowing interoceptive cues and acting in ways less authentic to oneself with others, the self is both (i) unable to be aware of and communicate one’s own emotional needs leading to burnout and (ii) has others reflect back to them inauthentic representations of themselves leading to the symptoms of identity disturbance that can be misdiagnosed as Borderline Personality Disorder. The boom and bust cycle of months of burnout following by recovery and 6-months of high achievement and functioning followed by another decline in function and burnout could at worst lead to the misdiagnosis of Bipolar Affective Disorder (Type II with hypomanic episodes) and at best lead to the complete erosion of confidence and competence in one’s own abilities across all functional domains of life.
The cost is proportional to the duration and intensity of camouflaging and masking.
Since this time, the topic of autism assessment has been an important feature of contemporary autism discourse particularly considering the significant mental health cost to individuals. Clinicians and researchers have been particularly interested in defining and measuring the construct to better assess these individuals often girls who as a result are misdiagnosed and treated for another condition, not diagnosed at all, or accurately diagnosed much later in life (Hull et al., 2019). Late diagnoses pose significant challenges, as prolonged engagement in compensatory behaviours reinforces early maladaptive schemas and coping modes. This ingrained pattern often correlates with severe mental health issues, including anxiety, depression, and self-harm (Cook et al., 2021).
The reason being that the degree of suppression of one’s emotions and sensory needs burns out one’s nervous system. On top of that the person is computing difficult ‘social algebra’, so as to “pretend to be normal” acting in inauthentic ways that leads others to misjudge what they need (referred to as a “miscue” in the language of Circle of Security (Cooper, Hoffman, & Powell, 2009).
Pervasive Camouflaging and Masking causes Significant Burnout so profound it is called Autistic Burnout.
Autistic burnout is a distinct phenomenon marked by chronic exhaustion, apathy, and a significant loss of functioning, which will resemble a severe major depressive episode although with a specific causal pathway. It results from prolonged exposure to social, sensory, and emotional stressors specific to autistic individuals (Attwood, Garnett & Hinze, 2023). Unlike general burnout, autistic burnout stems from the continuous effort needed to navigate environments and expectations that fail to accommodate neurodivergence. It often manifests after extended periods of masking or camouflaging autistic traits, leading to a depletion of emotional and cognitive resources and from clinical experience signs may show after 3 to 6-months (e.g. within the course of a university semester or by Term 3 or 4 at school).
In clinic my colleagues and I often observe that this state is further compounded by difficulties in interoception, making it harder for autistic individuals to recognize and be guided by their physical and emotional limits. Autistic burnout is not merely a response to occupational or academic stress but reflects a broader misalignment between the individual’s needs and the demands of their environment.
The phenomenon is more common than we understand with several local Brisbane examples.
In Brisbane at the local level, anecdotal reports from Admitting Specialist Psychiatrists and Paediatricians underscore the high cost of camouflaging and its links to recurrent mental health symptoms which can have a cyclical and pervasive nature and has been describe as cycles of Autistic Burnout. Colleagues working on the inpatient wards share that given the gender ratio of autism, there is a disproportionate amount of adult female patients often late diagnosed with autism who may present in these recurrent cycles once a year with severe struggles with dropping the masking and embracing their autistic identity (Psychiatrist Dr. Sharon Foley & Paediatrician, Professor Simon Denning Personal Communication July 2024).
Section 3. Current approaches to management. What strategies and supports have professionals are currently offered to clients experiencing autistic burnout?
Attwood, Garnett & Hinze (2024) summarised contemporary approaches to management of Autistic Burnout. They highlighted a multifaceted approach to recovering from autistic burnout, emphasizing self-awareness, rest, and environmental modifications as foundational steps. Recovery begins with recognizing burnout, a process often supported by trusted individuals who observe signs of exhaustion and withdrawal. Autistic individuals may struggle to identify these signs themselves due to interoceptive challenges. Key strategies include adopting energy-accounting techniques, pruning stress-inducing commitments, and fostering environments that reduce sensory overload. These approaches encourage individuals to embrace their authentic selves rather than masking or camouflaging. Rest is positioned as the cornerstone of recovery, offering essential solitude and sensory downtime to restore mental and emotional well-being. Other strategies, such as mindfulness, connecting with the autistic community, and participating in fulfilling activities, play a supportive role. This holistic perspective emphasizes individual flexibility, addressing the unique needs of each person on their path to recovery.
Issues with current management noted by Attwood and colleagues (2024).
Attwood and colleagues (2024) go on to note that despite its therapeutic potential, the recovery process faces significant challenges, particularly with the application of traditional cognitive-behavioural therapy (CBT). While CBT and behavioural activation are widely regarded as effective for treating depression, they may conflict with the needs of individuals experiencing autistic burnout. CBT’s focus on behavioural engagement and cognitive restructuring may not align with the autistic individual’s critical need for withdrawal, downtime, and rest during recovery. Furthermore, the reduced cognitive capacity inherent in burnout may limit the effectiveness of cognitively demanding therapies.
Additional issues identified at M&H: Underappreciation of Self-Organisation of parts as maintaining factors for recurrent episodes of burnout.
I believe a significant challenge in treating autistic burnout and why hospitals regularly see repeat patients in a cyclical fashion may lie in current management approaches that do not emphasise a multiplicity-of-self theory in their formulation and treatment plans. The two contemporary modalities that hold the presumption of the self as having multiple parts and are interested in getting to know the different “Parts” and functions are Internal Family Systems (herein IFS; Schwartz, 2020) or “Modes” as in Schema Therapy (herein ST; Brockman, 2023). Both IFS and ST are interested in the contexts and functions surrounding these parts or modes (herein used interchangeably) and it is our hypothesis that these parts or modes are at the core of what leads to recurrent cycles of autistic burnout and interfere with a person’s therapeutic recovery plan.
Not all clients presenting for therapy will need parts-work to progress but most if not all clients with very long-standing issues will.
For many therapists who do not work with clients who have experienced chronic invalidation or childhood trauma and whose training has been predominantly CBT the use of a parts model may not have been necessary to working with anxiety and depression. For these clinicians who are reading and haven’t come across multiplicity-of-self models before it is worth reading Bromberg (1996) for a history of the concept throughout psychoanalytic thought. A good starting point to understand parts is to think of an important decision you have had to make in your life and whether you noticed a part of you was in favour of making the decision and a part of you may have been in favour of not making the decisions. Importantly these models arose out of treatments for complex relational trauma where there was an observation that individuals who did not have core emotional needs met such as secure, stable, and understanding attachment, freedom to express behaviour and feelings, autonomy and competence, play, and reasonable boundaries, there is more probability of a person needing to adapt and ultimately exile certain vulnerable parts and develop other parts that function to cope in the family of origin but may be less well suited to an adult life outside the family of origin.
The need to adapt these approaches for Neurodiverse people.
Importantly these contemporary therapies have not been carefully adapted to suit neurodiverse presentations and require adaptations, however given that complex trauma is also really a neurodevelopmental condition with recent understandings of attachment and interpersonal neurobiology it is quite a smooth translation if one has been well informed about neurodiversity affirming practice already. An additional reason why these therapies which were initially successful for clients with complex trauma and personality disorder (i.e. strong coping modes/parts) is sadly the fact that there is a very high prevalence of trauma and relational trauma within the neurodiverse population often leading these approaches to be useful for a range of other long-standing mental health issues as well (Spicer, DeCicco, Clarke, Amborius, & Yalcin, 2024). I acknowledge the hard work that the team of clinicians developing the Stand Attuned Model of Schema Therapy have done and admire aspects of their model which I learnt about through the What’s the Schemata Podcast Episode 44 and has similarities to our approach.
Cases of recurrent Autistic Burnout are a good place to explore utilising a Schema Therapy approach.
Given the long ingrained patterns of masking and camouflaging, unfortunately while some parts of the person may be on board with aspects of the recovery plan, such as slowing down, tuning into interoceptive cues, engaging in energy accounting and relaxation, these new and different behaviours will be significantly triggering of a number of internal parts such as the critic making them feel unsafe given the memories of the past that difference is wrong which may echo into their present as feelings or if conscious with more of an ability to articulate that embracing difference and authenticity feels unsafe and wrong. Without attention to these aspects of self-organisation, treatment is unlikely to be completed and the person feeling somewhat recovered enough to start compensating and masking again may be off into the community once again playing out the cycle. Therefore, a major contribution of this blog is to emphasise that without attention to self-organisation of part or modes, then even when progress is made, these factors often contribute to the recurrence of burnout cycles.
After drawing out several more map illustrations for multiple clients with burnout who had a similar pattern of modes to their cycle I wondered if it would be helpful to have professionally illustrated and share with the community for feedback. While every individual’s case will be unique have a template to give voice to similar or different features may be a first step to raising one’s awareness of their own patterns of modes into conscious awareness giving rise to opportunities to choose to reconnect and/or rebuild old styles of coping into newer and more adaptive patterns. One of the first starting points for schema therapy is developing an awareness of schemas and modes and how one’s modes may be more activated or exiled in a given situation. I hope this example of a mode map is a useful starting point for clients to explore with their therapists or therapists to present as a conversation starter. If you would like to download this for use in therapy, please see the link here for $4.95.
Below are some case examples where parts might interfere with progress in therapy to reduce recurrent cycles of autistic burnout.
Example 1: Diagnostic Feedback Session
For many late-diagnosed autistic clients, the diagnostic feedback session serves as a transformative moment. It can trigger a release of long-held grief and an immediate reduction in stress and anxiety as they shed the burden of the expectations that were placed on them by society and thereby their inner neurotypical critic. Many of these individuals come back the next week or month having been released from longstanding symptoms of depression and anxiety. While this group appears to feel immediate relief following the discovery which is maintained long-term, there is another group for whom a part wants to accept the feedback that difference does not mean deficit but a large part of them feels that it is unsafe and wants to resist reframing their self-concept and treating themselves with greater compassion regarding one’s neurodiverse needs. This resistance underscores the challenges in integrating a new, more authentic sense of self into their identity, making it difficult to break free from entrenched cycles of burnout. When all parts of a person are not on board, a ST or IFS model becomes critical to make progress.
Example 2: Trying to Recovery Phase – Recharging environment externally, draining neurotypical critic internally
In recovery, certain Parts—such as the neurotypical inner critic—may become highly active during periods of scheduled rest or pleasurable activities. These parts often interpret restorative actions as signs of weakness, defectiveness, or low personal value, which undermines the recovery process. This internal conflict can perpetuate feelings of inadequacy and stall meaningful progress and lead to a repeat of disconnection with interoceptive experiences (Detached Protector) with over-compensation patterns (Social Overcompensation and Perfectionistic Over-Controller) as well as self-sacrificing and subjugation patterns (Compliant Surrender). Therefore while a person may be engaging in therapeutic recommendations for rest and recovery if their internal world (i.e. inner critic) is not carefully monitored they may not experience any benefit from this rest.
Example 3: Differential Diagnosis – Burnout Cycles Driven by Self-Organisation or Hypomanic Episode.
Across my career there have been several occasions when I have disagreed with a historical Bipolar (Type II) diagnosis when it appeared to be better explained by an autistic individual’s boom and bust cycles between depression/burnout and then periods of over-compensatory functioning which can appear hypo-manic. When collaborating with the treating Psychiatrist to share the information we have gathered from our consultations, having a mode model is useful to explain how cycles of emotion dysregulation can be driven by ego-dystonic anxiety (almost always fuelled by a neurotypical critic) rather than a co-occurring ego-syntonic elevated mood and goal-directed activity that might be seen in a co-occurring hypomanic episode (with little to no inner critic involvement) or cyclothymia. Therefore, a ST or IFS model can be a critical tool for careful formulation and differential diagnosis, particularly if the goal is to increase the clients awareness of interoception to connect to feelings and needs and some pharmacological approaches may have side-effects for a small group of people that reduce access to interoceptive input.
Example 4: During the Recovery Phase – Perfectionistic Over-controller/Social Over-compensator
During therapy, some clients exhibit overcompensating behaviours driven by social perfectionist parts. These parts compel them to complete homework assignments flawlessly and be the most polite and diligent client a psychologist has ever had despite them experiencing significant emotional and physical exhaustion. When a psychologist has favourable counter-transference towards a client it is useful to be alert to these modes in action and be aware not to reinforce these modes with praise and explore in process conversations. Clients may report that therapy is going well to gain the therapist’s approval, while either unaware or aware yet unable to overcome the emotional urge to compulsively carry out the maladaptive cycles that led to burnout. If unchecked this dynamic can ultimately result in repeated burnout, hospitalization, or suddenly ghosting the therapist. Therefore, when working with clients who may mask or camouflage and have not yet experiences too many cycles of burnout, formulating their case through a ST or IFS model may help with empathically labelling the people-pleasing modes so that they can be empathically confronted to get in touch with the needs of their more vulnerable parts behind the perfect façade that is terrified to disappoint or be perceived as not good enough. Catching the cycle early in the client’s life at the late childhood and adolescent stage could prevent years of mental ill-health, misdiagnoses and rotations through the mental health system.
Troubleshooting
There are a range of potential roadblocks in helping the client overcome this problem. Some of these include supporting trait-based and state-based alexithymia, treating co-occurring complex trauma or PTSD with EMDR Therapy, and healthy neurodivergent adult modelling. These trauma based psychotherapy models have many techniques to support and treat trait-based alexithymia and there are a range of methods to support and scaffold clients who require accommodations for trait-based alexithymia (Attwood, 2006) that we and other clinicians have added to at M&H over the years.
If you are a clinician who is curious to learn more about this model and you would like supervision on how to adapt schema therapy to neurodiverse populations to assist in the management of recurrent cycles of autistic burnout, please contact the clinic.
What are the next Steps?
If you are a client unfortunately my books for individual therapy have been closed although I do also supervise psychologists in our clinic on the approach if you would like to start therapy with one of my staff who has completed Schema Therapy Training. I do continue to provide diagnostic assessments for new clients, and I am also excited to announce I will be running group therapy sessions informed by this approach and the biographies and therapy workbooks created by neurodivergent people in 2025 with my colleague and co-director Dr David Zimmerman.
Section 4: Group Therapy at Minds & Hearts (M&H)
Group therapy as an adjunct to individual therapy for recurrent cycles of Burnout
One observation from individual therapy is that unmasking and revealing one’s vulnerable self in the 1-on-1 therapeutic space might be managable but transferring this openness to other social contexts of life (work, study, community) can be too far a leap where old modes have been ingrained for many years or decades. These groups aim to be an adjunct rather than substitute to individual therapy and aim to be a practical application of Cook, Crane & Mandy’s (2023) article “Dropping the Mask: It Takes Two”. The study explored autistic adults’ experiences of what they described as “authentic-feeling socializing” in comparison to camouflaging within mixed-neurotype interactions. The study identified four key themes based on qualitative data from 133 autistic participants and noted that when a context had accommodated autistic needs, as well as verbal and non-verbal communication styles, and encouraged autistic individuals to feel safe to act in more authentic ways, these interactions were reported to be less anxiety-inducing, cognitively demanding, and exhausting than camouflaging. These types of interactions were also noted by the participants to foster more genuine connections, reduced stress, and enhanced overall well-being which in schema therapy terms creates corrective emotional experiences that weaken maladaptive schemas that undergird the critic and coping modes.
Group 1: M&H Recover, Reconnect & Rebuild
This program is a novel yet tailored approach that has been designed by Clinical Psychologists and Directors of M&H Dr Hugh Walker and Dr David Zimmerman who have over 25-years’ experience of working with neurodiverse clients in assessment and psychotherapy. Hugh and David were trained under the supervision of Professor Tony Attwood and Dr Michelle Garnett, clinicians who pioneered what is now referred to as the neuroaffirming approach. The M&H Recover & Rebuild is a group that aims to support autistic adults who experience recurrent cycles of burnout and have the physical capacity to attend group sessions. The group offers a safe space to explore strategies for recovery and reconnect to interoceptive cues that signal emotional needs and reduce the intensity of future burnout cycles.
As described and illustrated in the article the group is neuroaffirming and based on a schema informed approach. The group will help participants to uncover aspects of the self, such as coping modes and internalised neurotypical critics that are bound to get in the way of recovery and relapse prevention. The group utilises skills from a range of therapies to recover, reframe and reconnect to one’s relationship with these aspects of the self while careful attention and support to the non-modifiable aspects of one’s neurodevelopmental condition where we aim to cultivate acceptance and self-compassion for our differences and natural limits. Other modalities such as Cognitive Behavioural Therapy (CBT), Dialectical Behaviour Therapy (DBT) Skills, Compassion-Focused Therapy (CFT), Acceptance Commitment Therapy (ACT), and Mindfulness-based principles will be incorporated into the therapy modules. Concurrent individual psychotherapy will be recommended for all participants completing the fortnightly group.
Eligible clients will have a diagnosis of autism and are aged 21-years or older. When indicated, participants can use their NDIS or receive a Medicare rebate through a GP MHCP Referral that recommends group therapy. For more questions about accessing the group or individual support for this issue please complete the M&H Contact Form here.
Group 2: The M&H Kindling Collective
The M&H Kindling Collective is for graduates of the Recover & Rebuild Autistic Burnout Group that is facilitated by Clinic Director, Dr Hugh Walker. The metaphor of Kindling refers to slowly adding fuel to the fire and keeping one’s energy balanced and accounted for. The Collective refers to the supportive nature of the group where peer-support can be invaluable when the desire to fall back into old maladaptive cycles of behaviours during life events arises. The group aims to build off the skills and understanding from the Recover & Rebuild Group though is less content driven and allows more space for connection, community, sense of belonging, burnout relapse-prevention and will encourage peer-support and peer-mentoring from group members.
Eligibility is for clients who completed 10-sessions of the M&H Recover & Rebuild program and are interested in relapse prevention of burnout. When indicated, participants can use their NDIS or receive a Medicare rebate through a GP MHCP Referral that recommends group therapy. We are taking expressions of interest for this group now to start mid 2025 if not earlier. For more details about the program please complete the M&H Contact Form here.
Written by
Dr Hugh Walker*
Clinical Psychologist | Clinic Director
- With acknowledgement to colleagues Dr Wesley Turner and Dr David Zimmerman as some of the ideas here are the culmination of many of our discussions together over the years.
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Books and Chapters
• Attwood, T. (1998). Asperger’s syndrome: A guide for parents and professionals. Jessica Kingsley Publishers.
• Attwood, T., Garnett, M., & Hinze, E. (2023). How do I recover from autistic burnout?
• Attwood, T., Garnett, M., & Hinze, E. (2023). What is autistic burnout?
• Attwood, T., Garnett, M., & Hinze, E. (2024). Understanding autistic burnout: When the world becomes overwhelming.
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9780890425596
• Brockman, R. (2023). Contextual schema therapy: An integrative approach to overcoming emotional dysregulation and complex trauma. New Harbinger Publications.
• Cooper, G., Hoffman, K., & Powell, B. (2009). Circle of security: Enhancing attachment in early parent-child relationships. Guilford Press.
• Freud, S. (1923). The ego and the id. Standard Edition, Vol. 19. London: Hogarth Press.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
• Schwartz, R. (2020). No bad parts: Healing trauma and restoring wholeness with the internal family systems model. Sounds True.
• Young, J. E. (1990). Cognitive therapy for personality disorders: A schema-focused approach. Professional Resource Press.
• Young, J., Klosko, J., & Weishaar, M. (2003). Schema therapy: A practitioner’s guide. Guilford Press.
• Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes. Harvard University Press.
Journal Articles
• Arntz, A., Jacob, G. A., Lee, C. W., Brand-de Wilde, O. M., Fassbinder, E., Harper, R. P., Lavender, A., Lockwood, G., Malogiannis, I. A., Ruths, F. A., Schweiger, U., Shaw, I. A., Zarbock, G., & Farrell, J. M. (2022). Effectiveness of predominantly group schema therapy and combined individual and group schema therapy for borderline personality disorder: A randomized clinical trial. JAMA Psychiatry, 79(4), 287–299. https://doi.org/10.1001/jamapsychiatry.2022.0010
• Barnes-Holmes, Y., Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2002). Relational frame theory: A post-Skinnerian account of human language and cognition. Advances in Child Development and Behavior, 28, 101–138.
• Bromberg, P. M. (1996). Standing in the spaces: The multiplicity of self and the psychoanalytic relationship. Contemporary Psychoanalysis, 32(4), 509–535.
• Cardoso, B. L. A., Lima, A. F. A., Costa, F. R. M., Loose, C., Liu, X., & Fabris, M. A. (2024). Sociocultural implications in the development of early maladaptive schemas in adolescents belonging to sexual and gender minorities. International Journal of Environmental Research and Public Health, 21(8), 971. https://doi.org/10.3390/ijerph21080971
• Cherewick, M., Matergia, M. Neurodiversity in Practice: a Conceptual Model of Autistic Strengths and Potential Mechanisms of Change to Support Positive Mental Health and Wellbeing in Autistic Children and Adolescents. Adv Neurodev Disord 8, 408–422 (2024). https://doi.org/10.1007/s41252-023-00348-z
• Cook, J. M., Crane, L., & Mandy, W. (2024). Dropping the mask: It takes two. Autism, 28(4), 831–842. https://doi.org/10.1177/13623613231183059
• Cook, J., Hull, L., Crane, L., & Mandy, W. (2021). Camouflaging in autism: A systematic review. Clinical Psychology Review. https://doi.org/10.1016/j.cpr.2021.102080
• DeCicco, E., Garrett, A., Smith, S.-L., Clarkson, K., & Ambrosius, R. (2023). STAND Attuned: Schema Therapy Adapted for Neurodivergence. Retrieved from https://www.alyssagarrett.com.au
• Fombonne, E. (2020). Camouflage and autism. Journal of Child Psychology and Psychiatry, 61(7), 735–738. https://doi.org/10.1111/jcpp.13296
• Frederickson, J. (2020). Co-creating safety: Healing the fragile patient. Seven Leaves Press.
• Hull, L., Petrides, K. V., Allison, C., Smith, P., Baron-Cohen, S., Lai, M.-C., & Mandy, W. (2018). Development and validation of the Camouflaging Autistic Traits Questionnaire (CAT-Q). Journal of Autism and Developmental Disorders, 49(3), 819–833. https://doi.org/10.1007/s10803-018-3792-6
• Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674
• Pantazakos, T., & Vanaken, G. J. (2023). Addressing the autism mental health crisis: the potential of phenomenology in neurodiversity-affirming clinical practices. Frontiers in psychology, 14, 1225152. https://doi.org/10.3389/fpsyg.2023.1225152
• Vuijk, R., Turner, W., Zimmerman, D., Walker, H., & Dandachi-FitzGerald, B. (2024). Schema therapy in adults with autism spectrum disorder: A scoping review. Clinical Psychology & Psychotherapy, 31(1), e2949. https://doi.org/10.1002/cpp.2949
• Vuijk, R., & Arntz, A. (2017). Schema therapy as treatment for adults with autism spectrum disorder and comorbid personality disorder: Protocol of a multiple-baseline case series study testing cognitive-behavioural and experiential interventions. Contemporary Clinical Trials Communications, 5(2), 80–85. https://doi.org/10.1016/j.conctc.2017.01.001
Illustrations and Personal Communication
• Minds & Hearts. (2024). Self-organization of parts/modes in autistic burnout. Design by Hugh Walker and Illustration by Hazel Ludlow.
• Personal communication, Dr. Sharon Foley and Professor Simon Denning, July 2024.