As a neurodiversity community self-advocate, I have come across far too many stories of emotional distress and trauma in connection with neurodivergent individuals’ lived behavioral therapy experiences. I understand where they’re coming from and I empathize. As a late-identified autistic, I, like them, have often felt disabled by society’s expectations around behavior which fail to sufficiently consider neurodivergence. The therapists mentioned in these stories held such expectations, clearly to the detriment of their clientele.
I have learned a great deal from neurodivergent individuals with all kinds of backgrounds as a result of my advocacy efforts. I have also learned from members of the clinical community as well as from my own clinical experiences, not many of which were effective with respect to skill-building and help with various personal challenges over the years. When I put it all together, it becomes apparent that greater understanding between the neurodiversity and clinical communities is sorely needed.
Greater understanding, so that a vulnerable segment of society experiences less hardship and more acceptance and successful therapeutic outcomes. So that the distrust which too many neurodivergent individuals hold for the clinical community can be addressed. So that the ways in which therapy is practiced in clinical settings become more neurodiversity-affirming.
If I were in a position to bring the clinical and neurodiversity communities together for a meaningful dialogue, I would start by proposing the following guidelines, derived from all that I have learned from others in both communities and from personal experience:
- Meet the client where they’re at. Do not start out based on where you want the client to be. Instead, design a therapeutic agenda based on each client’s unique sensitivities (sensory and emotional), thinking patterns, communication style, strengths, talents, abilities, challenges, and vulnerabilities.
- Communicate with the client in unambiguous, detailed, literal terms. Neurodivergent individuals tend to thrive in the midst of structure and certainty. Communicating in this fashion will cultivate this kind of therapeutic environment. If your neurodivergent clients are left to assume or infer what you mean, confusion or emotional unease may result.
- Nurture the client’s self-esteem. Be mindful not just of what you say but how you say it. Give high praise when the client takes a step in the right direction and when a goal is attained. Avoid setting the client up for failure by keeping your expectations down to Earth. Show acceptance and strongly encourage self-acceptance.
- Promote client self-advocacy, autonomy, and choice. Encourage clients to communicate which specific skills and challenges they want addressed, what they are not comfortable working on, when they are ready to move on to something else, when they need to take a break, etc.
- Monitor the client for signs of distress. Be wary of both verbal and non-verbal cues in this regard. Minimize the possibility of distress, trauma, and/or meltdowns by determining and implementing necessary accommodations at the outset. Confirming what triggered these outcomes in the past (if they did in fact occur prior to therapy) and mitigating the possibility of the emergence of such triggers would also help.
- Knowledge of the client’s neurotype is essential. Without an understanding of autism, ADHD, learning disabilities and other neurotypes that fall under the neurodiversity umbrella, those clients who exhibit them will be underserved or possibly harmed. Therapists need to be learning about these neurotypes from those of us who live and breathe them every day. A Google search on “neurodivergent writers” will reveal plenty of reading material worth checking out.
- Avoid referring to autism and other neurodivergent neurotypes as “disorders.” Many neurodivergent individuals view themselves as simply being different, rather than disordered. “Disorder” implies that we are abnormal, that we are broken and need to be fixed, that we are puzzles to be solved and that the only legitimate way forward for us is to become more neurotypical. What we need instead is acceptance and, ideally, to feel a sense of belonging.
The use of identity-first language is helpful in this case. Take, for example, “autistic person” and “person with autism.” Both may appear to mean the same thing, though they are not one and the same. The latter is indicative of person-first language, which to many would imply that autism is a disorder or a condition that should be treated or cured. Not so with the former, which is indicative of identity-first language.
- Absolutely no aversive interventions or punishment of any kind. These are highly likely to cause emotional distress or trauma and send a message to the client that they are not accepted for who they are. Therapy must focus on helping neurodivergent clients overcome challenges and develop skills on the client’s terms, not on resorting to punitive measures when the client says or does something to which the therapist objects.
- Ask the client to share their lived experiences. A neurodiversity-affirming therapeutic process must incorporate the neurodivergent client’s lived experiences. Otherwise, therapy inevitably proceeds blind, sharply increasing the likelihood of adverse outcomes.
- Input from somebody other than the client is worth considering only if the individual is a true ally. For example, when a parent or someone close needs to speak on behalf of the client, as may be the case with younger neurodivergent individuals. A true ally will speak to the client’s actual lived experiences, not over such experiences, ideally as if to be “walking in the client’s shoes.”
- Hold realistic expectations. If a therapist’s expectations are too inflated, the client is destined to fail, in which case self-esteem may be compromised. Expectations should be based on an assessment of the client’s strengths, challenges, and sensitivities. Patience is paramount in that progress is often made in small, incremental steps. Expectations also need to be flexible in that sometimes, the client may need to take a step or two back before moving forward toward a goal.
- Provide an environment in which it is safe for neurodivergent clients to unmask and bring forth their true, genuine selves. Many neurodivergent individuals have unfortunately been programmed to mask, often because of a desire to fit in or in response to trauma. As such, unmasking may take time, or it simply may not be possible. It is up to the therapist to create a safe environment in which clients are free to unmask without consequence, if they so choose. For example, the client should be allowed, if not encouraged, to stim in whatever way they need to in order to self-regulate, and to exhibit any quirky, idiosyncratic behaviors.
- Lead with humanity. Doing so entails showing compassion toward clients in a way that prioritizes the clients’ wants and needs. Show that you care and that you are there to help and facilitate rather than fix or cure. Exercise kindness and empathy.
Reform is needed now because one more instance of emotional distress or trauma resulting from therapy that disregards neurodivergence is one too many. This vision for neurodiversity-affirming therapy, or one that resembles it, would ideally help to rewrite the prevailing narrative.
Sam Farmer is a neurodiversity community self-advocate, writer/author, and public speaker. Diagnosed later in life as autistic, Sam shares stories of lived experiences, ideas, and insights as to how one can achieve greater happiness and success in the face of challenge and adversity. A Long Walk Down a Winding Road – Small Steps, Challenges, & Triumphs Through an Autistic Lens is his first book. Visit samfarmerauthor.com to learn more.