So I’m just going to write my own concerns, and general observations. I think a lot of us in the Au/DHD community recognise that our hormones massively affect us, and not in the same way as neurotypicals. In my opinion, hormones can affect your autistic brain in such ways as increasing or decreasing sensory overwhelm, increasing or decreasing our threshold for having a meltdown, and from an ADHD persective can have you being the most productive person on the planet one week, and unable to do the simplest of tasks the following week (and leave you with a huge Laundry Pile of Doom for your troubles).

With this in mind, I worry a lot about late-diagnosed autistics and/or ADHDers who are hitting menopause and promptly flung on a standard dose of HRT without the practitioner even having any awareness of how hormones affect us differently to neurotypicals. Healthcare also has this neuronormative standard, and it’s infuriating. In fact healthcare has a normative standard full stop, and tends to treat everyone the same – same standard dosage, same standard treatment, when we’re all so different. It literally makes no sense to me.

Anyway, I digress. My own experience of HRT has been both amazing, and very difficult – and to be super clear, this is just my own experience. Firstly, not everyone may decide to go on HRT for whatever reason. It’s completely an individual decision and certainly not a one-size-fits-all thing. And not everyone Au/DHD will react the same way as me to estrogen and progesterone either, but the point is – just have in the back of your mind if you do decide to go on HRT, that you’re not alone in your experiences of a) hormones and their effects, and b) trying to figure it all out!

I discovered that estrogen helps improve my ADHD symptoms, which makes sense since estrogen is involved with dopamine production. And thus when ADHDers hit menopause and our estrogen levels decline, our ADHD literally goes into complete overdrive and we’re left going.. what in the actual f*** just happened? (And also we’re left sitting here, sometimes in a sweaty, brain-fogged heap, wondering who/what decided that neurodivergence wasn’t enough to be dealing with without this hormonal clusterf*** on top of it?). I discovered that if I have too much progesterone in my system, Ritalin will 100% stop working. And again I think this kind of tracks with the menstrual cycle, and how there’s literally thousands of discussions online about “why the fuck does my ADHD medication not work up to half the dang month?!”

Now I want to be really clear about this and I’ll say it again, I am just talking about my own experience here. And as I mentioned already, every body is different, literally. But here’s things I wish I’d known before starting HRT:

• Sometimes it’s not the hormone that’s making you feel extra Au/DHD, it’s the method of application. So if you feel off on lets say estrogen via a patch, try all the other methods of application available, because you might just find one that suits you better. For me, I tried different brands of patch, gel, and now I’m on a spray which is definitely absorbing better.
• I found it very, very difficult on synthetic hormones. They just didn’t suit me, AuDHD and otherwise – I’m now on bioidentical/body-identical hormones i.e. estrogen and progesterone that is the same/similar to what your own body produces, rather than synthetic hormones. I also found that synthetic hormones didn’t help with things like bladder pain and UTI’s that can hit you during meno, and sex was painful (yes, we talk about it all on here!). Being on bioidentical helped both those things massively.
• Fluctuations – for me personally, I found the less fluctuation of hormones I have, the calmer my AuDHD brain is. So I’ve really worked towards being able to take the same dose of HRT every day with no breaks (and therefore no withdrawal bleed). If you still have a womb, you need to be on progesterone if you’re on estrogen, else your womb lining keeps building and there’s no signal to your body to shed it = very, very bad. But progesterone is what I’ve struggled hugely with, and it has taken me a long time to find the best type, brand and method of application – but again, don’t give up, because when the balance is there, what a difference it makes!
• Timing – again my AuDHD brain is very sensitive to fluctuations, even small ones. For example, lets say you’re prescribed a dose of 4 sprays of estrogen, you may find it easier on your AuDHD brain to do 2 sprays in the AM and 2 sprays in the PM, or do the whole lot in one go in the evening or the morning… experiment on what works best for you.

I’ll also say don’t give up on HRT if you find it does things like affect your threshold for sensory overwhelm, makes you want to have an autistic meltdown more, makes you feel like your PMDD is back to haunt you (oy, PMDD needs to be a whole other article..!). Because when balanced, HRT can also help with these things, in my opinion. And it all really tracks, because how many times have we seen in discussions online that at various points in the menstrual cycle you feel less sensory overwhelm vs. more, like a complete energiser bunny that spring cleans their whole house in 3 hours (AND cancels all your unused subscriptions) vs. do I even have a brain?.

So the same situation happens if you decide to get onto HRT, however you have a bit more say in it. And you can do a fair bit of trial and error with dosages, types… and yes, some methods of HRT application are in of themselves a bit of a sensory hell – the smell of Lenzetto estrogen spray is FOUL, however it absorbs for me so much better than patches, that I just spray it on my arm and stick it out the window until it’s dry, and have a peppermint oil rollon under my nose until it does. So if you see a woman waving her arm out the window haphazardly somewhere in Dublin, it’s me – and now you know why…

By Melanie Gruben

Cognitive-behavioural therapy, or CBT, is a form of therapy that is hot right now. With a glance at the literature it seems well-evidenced and nearly every corporation that is hiring therapists wants those who can practice it. Insurance companies go nuts for it. Podcasts and other media tout it. But how good is it, really, in the context of autism counselling?

CBT for Autism: Some Pros

Before I torpedo this modality later on, I want to address some benefits for our community. When looking for autism counselling, many autistics find cognitive behaviour therapy helpful for making sense of their thought patterns and changing some of their ways that hold them back. CBT has a very clear model and step-by-step processes; some people find this clarity and directiveness soothing.

There are a lot of written resources out there for CBT like worksheets and books; autistics love a good research deep dive and we can be more thorough when there is a lot of content! CBT incorporates routine, which can be great for autistics in the right context.

The concept behind CBT is that adapting your thinking/feeling/behaviour patterns is one way to kick anxiety and depression and get out of unhealthy cycles. Depending on what your patterns are and why they are causing harm, CBT may be an empirically supported quick fix.

Problems with CBT for Autism

Autistics who are learning to unmask and have experience with CBT might already see the problem, though: CBT is based on the premise that the source of your problems might be the way that you are, internally, and that changing yourself is likely the answer. CBT’s main approach is challenging your thinking as if it is flawed.

CBT Can Become Glorified Masking

But what if you have spent your whole life doubting your natural ways of thinking, feeling, and behaving, and that self-denial has been your main source of distress? CBT can start to feel like gaslighting.

As an example, autistic people are often anxious in social situations after years of rejection and hostility. Is the answer to do mental exercises to manage the anxiety or dismiss it as irrational? Or find a better friends group and work toward allowing yourself to not socialise when you don’t feel up to taking risks? Or some third thing?

It’s not always worksheets, is my point – maybe your anxiety is understandable.

Western Psychology & Toxic Individualism

This is one of the failings of Western psychology. It is individualistic in origin and often focuses on solely on developing the inner self as if nothing else is changeable.

But we can affect changes in our environments and our communities, and sometimes mental health is recognising that not all your problems are of your own creation.

And sometimes, your place of work or study is the one that needs to change. It is possible to self-advocate without falling into self-indulgence. It is possible to defy ableist norms without abandoning the inner work.

What Else is CBT Good For?

CBT can be very effective for short-term interventions. It can be great for panic attacks, if what you’re looking at is actually panic attacks and not meltdowns. (Sidebar: autism counselling can be good for telling these apart). CBT was developed to get people out of crisis and it works for that. Some people also find it helpful for specific mental health experiences that are based on maladaptive thinking, like disordered eating.

Unfortunately because CBT claims to have measurable metrics and those metrics look good and fast-acting, capitalism took off with it and it gets overprescribed.

It’s also not as helpful for long-term growth arcs; it’s not built for that. Often we go to therapy for long-term growth. Companies will rarely pay for more than six or 12 sessions though; they are not interested in helping you figure out why you have bad dreams about your dad. Getting you back to work though? That they will invest in. CBT’s popularity is coloured by this.

Does Your Autism Need Fixing?

At its core, CBT is a fixer. It is designed to identify problems and make fast solutions for them.

Maybe you are seeking therapy as an autistic person because you are struggling. Are you sure your thoughts, feelings, and behaviours are the problem?

For many autistics, unlearning shame/ableism, expanding self-compassion, and making lifestyle changes are key to mental health. Maybe you feel you have some problematic patterns and a mixture of CBT and something else would be helpful.

There’s nothing wrong with holding yourself accountable. But at the end of the day, a lot of autistics overestimate how much is “wrong” with them.

Don’t let the overuse of this modality influence you into doubting your experience.

The Bottom Line

So, does CBT work for autism? CBT is good for some things in some contexts.

Still, my general impression is that it’s done more harm than good for autistics in the context of therapy. Other experts will argue with me.

It might be helpful to think about what you are hoping to get out of therapy and whether CBT will help you meet those goals. It can also be something you collaborate with with your therapist to change up how much CBT is mixed in. Personally, I find the humanistic method most helpful for moving toward a neuro-affirming lifestyle, and mileage will vary.

Melanie is psychologist accredited with the Psychological Society of Ireland and a researcher. She is based in Limerick, Ireland and works online providing class-conscious, queer, transfeminist, ENM and kink-aware neurodivergent psychotherapy for Ireland, the UK, and Europe. Melanie’s life goals include learning when to use the “ser” and “estar” verbs in Spanish and keeping a single English ivy plant alive. For more information visit melaniegrubentherapy.com.