Neurodivergent in Therapy
I’m a neurodivergent therapist, and I work almost exclusively with autistic and otherwise neurodivergent folks in my therapy practice. I’ve heard countless stories about what it’s like for neurodivergent people to be in therapy. Experiences range from helpful to horrific. It makes a lot of sense why neurodivergent folks are hesitant to engage or re-engage in a process that doesn’t appear to be attuned to their needs. Although there’s been more awareness in recent years, the mental health field has a long way to go to provide consistently helpful care for neurodivergent people.
Attunement and therapeutic alliance are some of the most important factors guiding success in therapy. This means having a sense that your therapist gets you is pretty darn important. In my clinical experience, it’s common for people who are neurodivergent (referring to autism and/or ADHD here) to not experience attunement in typical ways, and they may struggle to connect effectively with their therapists. Sometimes what is considered a “reasonable assumption” based on unwritten social rules, is not accurate for neurodivergent folks. With regards to autism, there is evidence to suggest that it is difficult for people who are not autistic, sometimes called “allistic,” to empathize and understand the intentions and communication style of autistic people. Without proper training, even well-meaning therapists can cause poor treatment outcomes and potentially harm.
Surprisingly, we don’t learn much about neurodivergence or the neurodiversity paradigm in graduate school. At least not in the curriculum on the master’s degree level. I was lucky enough to learn a lot from my peers and field placements, but it’s certainly not a given. Since finishing my education, I have had to seek out the training and other learning opportunities to effectively modify treatment models. My lived experience has also helped (perhaps the most.) These trainings are becoming more common, but they’re still hard to come by and sometimes unaffordable. Training is also required to make sure we are checking our biases about neurodiversity and other disabilities. Even though I am neurodivergent myself, I am still prone to internalized ableism (we all are.)
Ableism is a major factor in the harm caused by therapists when working with neurodivergent clients. Ableism is discrimination based on disability. This presents in many different ways and every disability/disabled person is different. Sometimes the assumptions made by under-trained therapists may lead to misdiagnosis, incoherent feedback, and overall invalidation. Having your friends, coworkers, and family members misunderstand you is one thing, but when it’s a therapist it just hits different. It can recreate harmful experiences that clients have outside of therapy, and cause them to think “I’m even too broken for therapy to help.”
Perpetuating behaviors that lead to burnout is one way these ableist misunderstandings can negatively affect autistic people. Autistic burnout (not to be lumped in with vocational burnout) is something that many autistic people go through when the demands of life are too much. It leads to physical and psychological symptoms that can be extreme. Some have described it as not being able to think or move and can be summed up as “I just can’t do it anymore.” Autistic burnout can sometimes last years.
There are times burnout can look like depression. Sometimes it can even truly include depression, but the treatment is very different. One of the interventions for depression is called “behavioral activation.” Essentially, behavioral activation is when a therapist supports clients by helping them engage in rewarding activities despite depression convincing them they won’t be rewarding. This is a well known and effective treatment for depression. Autistic burnout, however, is not depression. The treatment for burnout is primarily decreasing demands. This is kind of contradictory, and if you think it’s depression, you may get stuck in a loop of trying to “do more.” That’s not really aligned with decreasing demands. There are many other treatments when applied to neurodivergent clients, may not that yield the intended results or can make the challenges worse. I think most therapists are well meaning, but these are the types of things I hear in my therapy practice often, and I sigh. Also, frankly, I’ve been there, done that.
I can sense a shift beginning to happen in the mental health world toward a neurodiversity affirming model. I am optimistic that the field will continue to open up to this model and we will have more people who are able to flag, understand, and treat neurodivergent clients. Being a neurodiversity-affirming therapist means understanding that each person’s mind is unique. We should be more curious about each client’s internal world, and trust that only they can know what’s best for them. Therapy should be tailored to each individual, with less assumptions about the causes of our clients’ pain. I use my knowledge as someone who has studied neurodivergence extensively to filter information through that lens, so that I don’t miss something important about my clients’ experience.
Neurodivergence is not something to be cured or fixed, but neurodivergent folks often need mental health support. To meet this need, current and future therapists need more support themselves. We need more training and better education. What neurodivergent folks don’t need are cures, rigid intervention, shaming, or surveillance. I can see a world in which the mental health space is safer for neurodivergent folks, but we must address the harms first to inch toward safety.
