Is it skill regression, or is it ineffective therapy?

Language note: I will be using the terms "diagnosis," "discovery," and "identification" throughout this blog interchangeably because not everyone who is autistic has, wants, or can access a diagnosis. Furthermore, I do not subscribe to the medical model of autism, and when I use the term, it's referring to a social identity, not a disorder.

One of the most common concerns I hear from autistic adults in therapy after having recently learned about their autism is some version of, "I feel like I'm doing worse than I was before." Sometimes that looks like struggling more at work or noticing sensory overwhelm they previously pushed through. Often there's an onset of or uptick in visible meltdowns or shutdowns. All of these things reasonably lead people to wonder whether therapy is helping or hurting.

When this happens, they're often reassured, "This is normal, it's skill regression." This may be true! But when that explanation becomes the end of the conversation rather than the beginning, the individual becomes vulnerable to therapy harm. It's a therapist's responsibility to support their clients in differentiating a potential mismatch in support from an expected part of the unmasking process, so let's talk about what that looks like.

What do we mean by "skill regression"?

This term is used to describe a phenomenon that occurs very commonly following a late (i.e. absolescence to adulthood) identification of autism that includes:

• Burnout making it harder to maintain previously learned coping strategies

• Reduced capacity to sustain masking

• Increased awareness of needs that were previously ignored

• Giving themselves permission to stop performing neurotypicality

• Grief, anger, or exhaustion surfacing after years of self-suppression

In these situations, it can absolutely look like someone is functioning "worse" now that they know they're autistic, perhaps leading to the conclusion that it is that awareness that caused the problem. For example, someone who once forced eye contact stops doing so. Someone who used to tolerate loud environments may start declining invitations. Someone who pushed through overwhelming situations may begin leaving early, asking for accommodations, or staying home altogether. To outsiders, it seems reasonable to conclude that it's the diagnosis or discovery of autism that made them less capable. But that's more of a leap than you might realize.

As an autistic therapist supporting autistic adults, nothing grinds my gears quite like hearing family members and support people remark that so-called skill regression is evidence that people were better off before knowing they were autistic. I can't tell you how many folks over the years found out in adulthood that they were actually assessed for or diagnosed with autism in childhood but that their parents chose to keep it from them because they assumed that it would lead to learned helplessness and "making excuses." These conclusions mistake correlation for causation. The issue is rarely that someone learned they were autistic. More often, it provided a framework for understanding needs, limits, and exhaustion that were already present. Think of it this way: the diagnosis didn't create the fire, but it helped identify the smoke.

The question we should be asking

When someone appears to be and/or reports functioning worse after diagnosis or during therapy, I think there's a much more useful question than "Is this skill regression?" That is: "What is the corresponding gain?" In other words, what are they getting in return for what they're losing? For example, does the decrease in productivity come with fewer meltdowns? Does heightened sensory sensitivity mean less dissociation? Does the increase in visible distress come wtih greater self-awareness? Are more boundaries leading to healthier relationships? Does the inability to mask create space for more authenticity and self-respect?

These situations can still be painful, as they involve real losses. But there is at least a visible tradeoff occurring. Something is being gained. In contrast, if someone reports lower functioning, more isolation, more anxiety, less hope, less connection, less meaning, and/or less agency and no meaningful improvements elsewhere, then it becomes important to ask harder questions. Skill regression is a description of what is happening, but it's not proof that what is happening is healthy or necessary.

When support people think therapy isn't working

This conversation becomes especially complicated when loved ones are involved. It's common for family members to express concern that therapy isn't helping because they notice behaviors that weren't present before. We often unconsciously look for consistency to signal wellness and equate behavior change with a problem. Maybe the autistic person has started to say "No," "I'm overwhelmed," I need a break," "I can't do that today," or "That environment isn't accessible for me" for the very first time.

When that happens, I tend to celebrate my client's progress while also keeping in mind that supports who have known this individual far longer than I have may have useful insights to offer that aren't definitely rooted in unfamiliarty or ableism. Usually it depends on the context of the relationship. If my client values and trusts a loved one's feedback as relevant, so will I, and if they report having always felt that love was conditional, I will be cautious in how and if I integrate it into my conceptualization of what's going on.

Sometimes what they're witnessing is unmasking; sometimes it's the unraveling of a lifetime of compliance; sometimes it's baby steps toward self-advocacy. These changes can be inconvenient. When someone has spent years prioritizing other people's comfort over their own needs, their recovery may initially create discomfort for the people around them. That doesn't automatically mean therapy is failing. At the same time, autistic people often find these reactions deeply painful. Imagine finally understanding yourself, finally finding language for your needs, finally beginning to advocate for yourself, and then hearing, "You seemed better before therapy." What many of us actually hear in that moment is, "You were easier for me before therapy."

Therapists don't get a free pass

While I often see family members mistake. unmasking for deterioration, I also worry about the opposite problem. Sometimes therapists use concepts like burnout, grief, unmasking, or skill regression to dismiss legitimate concerns about therapy. For example, a client says, "I think I'm doing worse," and the therapists responds, "Trust the process."

Good therapy should be able to tolerate scrutiny. If a client expresses concern that therapy isn't helping, the therapist's job is not to defend the treatment. Our job is to become curious. What specifically is getting worse? What specifically is getting better? How does this assessment stack up against the goals the client has set for themselves? What evidence suggests this process is moving in a trajectory that will take them toward those goals? What would indicate that the current approach is not working? How long should we reasonably expect this phase to last? What alternative explanations should we consider?

To be clear, I primarily do long-term work in therapy, so I am certainly not coming from a managed-care-informed perspective that insists therapy look like manualized, concrete, observable, measurable and time-limited progress being made and re-evaluated week to week. And yet, if we can't say, "This is the thing we're doing that makes this therapeutic, and here's how I know," we do have an ethical obligation to revisit the plan. A therapist should be willing to acknowledge uncertainty and to consider whether another approach or another provider might be a better fit.

Therapy should increase possibility

A diagnosis should provide explanation, but it should also expand possibility. It should help someone understand, "Oh, that's why this has been happening" and then help them to ask, "Given that reality, what do I want to do next?" Similarly, therapy should not simply explain suffering. It should create opportunities for a life that feels more sustainable, more meaningful, and more aligned with that person's values.

To be fair, that latter part might take a while to take shape. Years, even, especially for people who went decades with an entirely different self-concept. I probably say, "That makes sense!" ten times a day as I form a narrative about why someone is doing what they're doing. We need our behavior to make sense...to figure out what need it meets, to access compassion for ourselves, before we can move into the expansion, or the "Now what?" phase.

Therapy (other than compliance-based behavioral therapy, anyway) is not designed to help you become the easiest version of yourself for other people. It's not meant to ensure you m maintain appearances at any cost. The goal is not accept every loss of functioning as inevitable or healthy. It's to build a life that works better. If therapy is leading to difficult changes, it's worth asking what you're getting in return for the loss. The answer won't always be obvious. But if neither you nor your therapist can identify any corresponding gains, that's a reason for deeper conversation, not shame.

A final thought: we need a grey in between the pathologizing stance that "autism is just an excuse" and the overly simplistic affirming stance that "all regression is actually growth." We need room for the dialectic that unmasking can be painful and valuable while still checking in to make sure that those we are seeking help from are actually helping.