What Even The Best Therapists Don't Get About Their Neurodivergent Clients
Even great therapists need to understand autistic and ADHD folks better for therapy to be supportive, says one neurodivergent writer.
Peopleimages.com - YuriArcurs | Canva “You need to stop looking for things that are wrong with you. Now you’re saying you have anxiety. Just let that go.”
“We’ll need to wrap these sessions up soon because you’re doing well.”
I was in therapy on and off for 15 years, and these two comments from a counselor in my mid-30s were on the more invalidating end of the scale. Therapy was my lifeline each week, yet when I heard things like this, I felt ashamed, unseen, unheard, and, most of all, misunderstood. As a neurodivergent person (autistic and ADHD), I’m not unique in finding a lot of therapy unhelpful.
Many people who are autistic or have ADHD (or both, which is very common, according to a 2022 analysis published by Frontiers in Psychology), the two types of neurodivergence I’ll focus on here, aren’t diagnosed until they reach adulthood. They often make it to midlife without knowing the core thing that underlies their struggles: Their brains and nervous systems are wired differently than the majority and don’t match up with societal expectations. This alone causes an incredible amount of stress and suffering.
It’s not a case of “just trying harder,” the subtext of what many a neurodivergent person has heard from a well-meaning but ill-advised therapist. It’s like living as a Linux operating system in a Windows world. In 2022, the Division of Cancer Epidemiology and Genetics reported that the 15% of the global population that are neurodivergent need different operating instructions, and if they’ve come to a therapist for help, they need that professional to help them figure those out, rather than imposing the same things that have forced them to mask who they are their entire lives.
Unfortunately, most therapists are not experts in ADHD or autism, and the training they’ve received is usually based on outdated research and misconceptions, according to an analysis published in 2021 by the National Autistic Society.
When I read the accounts of neurodivergent folks sharing what they wished therapists could know about them based on their therapy experiences, I discovered I was not alone in my less-than-stellar reviews of my therapists. I will draw on some of the experiences of my fellow neurodivergents, but due to the private nature of the group, I will share them as aggregates rather than as specific comments.
What even the best therapists don't get about their neurodivergent clients:
1. Neurodivergent clients don’t process their emotions the same way
All too often, therapists and psychologists come to their work from a place of assuming that when someone acts in a certain way, it means they are feeling a particular thing. Not so when alexithymia is in the picture, referring to difficulty with knowing what you are feeling or how to name what you are feeling, or in showing “socially appropriate emotions,” according to the charity Autistica.
Although alexithymia is not a core feature of autism, recent studies have found varying degrees of this trait in 50 to 85% of autistic individuals, which is far higher than the 10% rate in the general population, reported by Living Autism. That client who seems “avoidant” of their feelings in the therapy room may just be dealing with alexithymia.
“Lack of ability to name feelings is one reason why an ND [neurodivergent] person may find life difficult and be bullied and abused because they are simply unable to express what they are feeling or protest against it,” says therapist Tania Glyd.
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“When you have been stigmatized because of who you are, you may well have learned to hold back as an aspect of masking for safety,” Glyde continues. “If the client says they don’t know the answer to something or cannot name how they are feeling, this is not an invitation for the therapist to start pushing them as if they are hiding the truth from themselves.”
Autistic/ADHD YouTube creator Samantha Stein brilliantly describes what it’s like to live with alexithymia in this 7-minute video. Samantha, or “Yo Samdy Sam” as she’s playfully known on YouTube, explains that for her, it’s not always about difficulty with naming an emotion. Instead, it’s about connecting the emotion to a felt experience in the body. “It has taken years of therapy to even realize when blood rushes to my arms, and it means I’m angry, or when there’s a falling feeling in the pit of my stomach, that means I’m anxious.”
I resonate with Samantha’s tendency to have such a complex emotional stew going on that it’s impossible to give a concise reply to the simple question “How are you?”
The most frustrating thing is feeling like my therapists fell for my mask when, after years of being misunderstood and bullied, my deepest longing was to be known and understood in a safe space. Like others in the neurodivergent advocacy group, I experienced therapists as being convinced by my ability to articulate and analyze my issues yet failing to recognize that I was struggling a lot more than it appeared.
They couldn’t see that just because I had a lot of self-awareness, it didn’t mean I didn’t need help. I experienced little benefit from talking about my problems, week after week, because I wasn’t connecting the dots, and my therapists didn’t know how to help me do so. Nothing in my demeanor showed anxiety because I had perfected my mask over years of trying to fit in and look as if I was coping while I was dying inside.
The fact that an autistic brain, even at rest, is already working harder at processing means it’s challenging to get a grip on emotions. Autistic writer Jae L writes, “Paying attention to and appraising our internal emotional state is part of the bigger picture of sensory and cognitive processing. The more that the brain has to process, the harder it is going to be to tune into anything, including the signals from inside ourselves. If you can’t process emotions, you can’t identify or describe them.”
With neurodivergent clients, therapists need to widen their view of what expressing feelings looks like. “A client may express feelings via all sorts of media, metaphor, simile, imagery, sounds, movements, creativity as a whole, and their special interests, rather than direct description,” says therapist Tania Glyde.
As an autistic person, I have found the emotion wheel, created by Robert Plutchik, to be a helpful tool. The emotions in the outer ring are easy enough for me to name, but getting to the ones in the middle is often a challenge.
2. What seems unhealthy may be normal for neurodivergent clients
Most training for mental health professionals is based on how neurodivergent people look or come across to neurotypical people, says Katherine May, autistic advocate, writer, and bestselling author, in one of the best interviews I’ve heard on the subject of what it’s like to be autistic. The typical therapist’s picture of neurodivergent reality is, therefore, based on a neurotypical-centered bias and hinges on a view of deficits rather than differences.
This doesn’t take into account the way that neurodivergent people process information differently, for example, monotropism and sensory sensitivity, and the fact that lots of behavior makes sense when seen in this light.
There is a misconception that autistics feel less when, often, they feel more — but because they’re being studied from the outside, all that’s observed is behavior that looks different to others rather than how they are feeling. “Hyper empathy” is the term May uses to describe it, explaining how she feels others’ emotions as physical sensations and is almost in physical pain if someone else in the room is embarrassed.
When there’s so much going on in our internal world, but we know it would be considered odd to show it, no wonder our faces don’t match our insides. In recent years, there has been a surge of voices coming forward, sharing the experience of neurodiversity from the inside and countering the disturbingly persistent messages that if you’re autistic, you can’t have relationships, be successful or happy, or even love and be loved (Katherine May was, shockingly, asked after giving a talk if she, as an autistic, was able to love her daughter).
Janae Elisabeth, aka Trauma Geek, is an autistic researcher-storyteller and neurodiversity advocate. She, like Katherine, is another powerful voice in the neurodiversity field. In this quote, she gets to the heart of why the research at the base of most mental health professionals’ autism knowledge is so flawed:
My autistic social engagement system [referring to the branch of the nervous system that governs social interactions] is not dysfunctional. My social engagement system hears every nuance in your voice, tracks your body language, and builds a complex, editable picture of who you are as a person.
What’s at the heart of the issue, rather than an inherent dysfunction, is that she “struggle[s] to access safety.”
I struggle to be seen by your social engagement system as anything other than a threat because I am not normal, and normal feels safe to you. I struggle to feel safe in clinical environments where you test my body’s responses for presumed dysfunction.
To researchers who pre-assume a deficit, the presentation of the hyper-function of the social engagement system will never be apparent. You will continue to test for dysfunction and receive results that appear to verify their hypothesis, but you are fundamentally wrong.
Elisabeth explains that the reason autistic people so often struggle with social engagement is that most of them have developmental trauma or complex PTSD (due to growing up autistic without the necessary support and understanding). “When autistic people struggle to access their social engagement system, it is not because our nervous systems are inherently flawed, it is because we lack safety.” What, then, would make the client feel safer is something to explore — with an open mind.
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3. Self-care, healing, and recovery look different for neurodivergent clients
The impact of stress on a neurodivergent might not look the way therapists expect it to, and things that aren’t stressful to the typical client could profoundly affect a neurodivergent one. Autistic burnout and ADHD burnout, for example, can result from things that may appear insignificant to a neurotypical, who can take these things in their stride due to a less sensitive nervous system and a brain that processes information differently.
From the “outside-in” perspective, a therapist may assume a client who avoids social situations is dealing with social anxiety when, in fact, it’s adaptive (normal) autistic behavior to reduce sensory overload and the exhaustion of regular masking. In this context, spending more time alone is vital.
It would be easy to label someone who stays in bed for days, watching Netflix, as depressed. If this person were also to show little to no response to distressing news, this impression could deepen. An alternative possibility is that this behavior could indicate what’s known as dorsal vagal shutdown in nervous system terminology.
“Especially for people who are neurodivergent, like those who are autistic, a dorsal vagal shutdown is a key concept for understanding our distinct responses to stress,” writes neurodivergent clinician Megan Neff, Psy.D on her blog Neurodivergent Insights. Emerging research indicates that, compared to non-autistic individuals, autistics are more likely to experience a shutdown response to stress rather than a fight-or-flight reaction. “This can manifest as an outward appearance of calmness, masking significant internal disconnection and immobility.”
Janae Elisabeth lists “100% healthy healing behaviors” that she finds necessary to avoid a full dorsal vagal shutdown, particularly in the context of long-term trauma recovery. Therapists might find it surprising.
Her list of “dorsal rest” activities includes nesting and naps, comfort food, time and space alone, low-energy activities (listening to music, watching Netflix, reading, coloring, yin yoga), sensory defenses (shades drawn, headphones on, soft blankets), and doing “nothing” (daydreaming, spacing out, losing time).
“If I shame myself for any of these, I quickly find myself out of dorsal rest and into dorsal freeze,” she adds, referring to the shutdown state of the nervous system, which can incapacitate a person, as discussed by Neff.
A therapist who is unaware of these nuances may inadvertently shame the client, encouraging them to “get out there” and activate their ventral vagal nervous system, the branch of the nervous system governing social engagement. Instead, they may need encouragement and support to restore in the ways Elisabeth suggests.
For the autistic client avoiding social situations, instead of gearing therapy towards reducing fear so they can reach the neurotypical goals of regular social group participation, the therapist should aim to explore what this client’s needs for connection are and how they are best met. This could be through exclusively online connection or occasional one-to-one meetings with a trusted friend or fellow autistic person.
Autistic researcher and specialist consultant Sarah Hendrickx says it well, referring to advocates, but her words are equally applicable to any mental health professional supporting an autistic person:
My idea of happiness is solitude and silence or rewriting my schedule for the next month over and over again. If an [autistic] advocate thinks that happiness is lots of social interaction and reducing repetitive behaviors, then we do not have the same goal. Advocates must respect autistic people’s right to choose a life that suits them, not necessarily a societal norm. Judging people’s life choices as wrong because they are different is not acceptable.
4. Neurodivergent clients are often misdiagnosed
The knock-on effects of living with neurodivergence in a neurotypical world can certainly increase the chances of mental illness, say experts at Embracing Complexity in 2021, a special interest research group. 70% of Autistic people will be diagnosed with at least one mental health problem at some point in their lives, according to clinical psychologist and neurodiversity advocate Alice Nicholls, DClinPsy.
The picture is made more complex by the fact that many women, in particular, are let down by a psychiatric diagnostic system that mistakes their neurodivergence for mental illness, according to ADHD coach and researcher Tracy Otsuka in her book, ADHD for Smart Ass Women. This is because ADHD, as it presents in women, is still relatively misunderstood since the symptoms can be internalized to a greater degree than in men.
Without the appearance of obvious external hyperactivity, the mood and energy swings characteristic of ADHD and the difficulties with emotional regulation could be seen as symptoms of bipolar disorder or borderline personality disorder. Many women, therefore, end up without the correct support, creating a spiraling situation of unmanageable symptoms. This is also due to the ADHD studies that formed diagnostic criteria being based on males, says Otsuka.
As Devon Price points out in his ground-breaking book Unmasking Autism, autism is often missed because it doesn’t present in the way that it does in white males, which most studies, and, therefore, the diagnostic criteria, have been based on. Autistic specialist Sarah Hendrickx teaches about how to identify autism in those who don’t fit the typical profile, often women and girls. Once again, it’s a recipe for feeling frustratingly and dishearteningly misunderstood as a therapy client.
In the general population, overlapping symptoms between borderline personality disorder, ADHD, and autism can easily confuse, says neurodivergent clinician Megan Neff, and to muddy the waters even further, they co-occur at higher rates with these forms of neurodivergence. The pressure to mask and the continual demands of sensory overwhelm and lack of rest and recovery time can lead to autistic burnout, which can be mistaken for depression, says Neff.
Autistic traits like being uncomfortable with eye contact or hating large crowds can be taken for simple social anxiety, and the autism is missed, writes autistic writer Shamiha Said. The high-speed talking and fidgeting of an ADHDer can also be read as anxiety. Or it can happen the other way around — once people are diagnosed with ADHD or autism, the diagnosable disorder of anxiety can be explained away as part of those conditions and not properly treated. Equally, just because someone can make eye contact doesn’t mean they’re not autistic. It’s a spectrum, after all, as explained by a 2019 article published by NeuroClastic.
To counter these mistakes, mental health practitioners such as psychologists, psychiatrists, psychotherapists, and counselors must have the most up-to-date training in recognizing neurodivergence in all ages and genders and be aware of different presentations across ethnic backgrounds.
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5. Cognitive behavioral therapy (CBT) isn’t always a good fit for neurodivergent clients
What about the methods used in therapy sessions? From the outset, whatever therapy modalities are used, the therapy situation itself presents inherent additional stress to autistic clients because it’s a social situation with all the associated demands, especially as the well-practiced tendency to mask is likely to kick in.
For ADHD clients, it might be difficult to stay focused and on track in their communication during a session without going on tangents. This might be seen as “avoidance,” but according to a recent article by NeuroLaunch, it is the result of a mind that more easily makes associations between many things and has less of a filter for irrelevant stimuli.
The Americal Psychological Association (APA) defines cognitive behavior therapy (CBT) as a popular form of therapy, often prescribed by medical professionals, that uses techniques for challenging our thoughts and beliefs. “These techniques assume the client has a high degree of flexibility in the way they think and that they can be taught to use alternative strategies for interpreting situations and information,” says clinician Alice Nicholls.
Many autistic people, however, find changing the way that they select, process, and interpret information very difficult, and this is borne out by research, says Nicholls. She suggests that better results can be found by helping therapy clients focus on their behavior rather than their thinking style.
For ADHDers who are already struggling with attention, memory, and organization issues, the requirement of CBT to keep track of their thoughts and emotions during and outside of therapy sessions is extra challenging, making CBT ineffective, according to a recent article by MindVoyage. I feel I have about a thousand thoughts per second, so corralling them all into a trackable form would be impossible. When a therapist questions your thoughts, as in CBT, this can also be experienced as invalidating, which is something ADHDers and autistic folks have usually experienced more than most.
CBT also leaves out the fact that the external environment of the client may need to change, not just the internal one. “No one (neurodivergent or not) should be encouraged to see their thinking as defective and be encouraged to change their behavior as if they are the one at fault when the issues are likely their environment and lack of [neurodivergent-aware] accommodations,” says therapist Tania Glyde.
There are some excellent suggestions for neurodivergent-friendly alternatives to CBT in this article from Autism Understanding, including “listening to the person’s story and then finding strategies together that would suit their needs, interests, lifestyle.” This encompasses troubleshooting social, family, or work situations they are struggling with. For example, an ADHDer may need support to find ways of introducing more novelty and interest into everyday activities that they get stuck on.
6. Mindfulness isn’t a cure-all for neurodivergent clients
Mindfulness has become an increasingly popular go-to in therapeutic settings, especially with anxiety or depression. Neurodivergents who have experienced unhelpful therapy explain that focusing on the way mindfulness is required can be very challenging.
Techniques such as focusing on breathing, sounds, and sensations can increase rather than decrease stress. This could be because ADHDers already cope with increased sensory sensitivity, as do autistics, and because they both tend to struggle with interoception, which is the perception of signals from one’s own body, such as being hungry or tired.
Instead of assuming traditional mindfulness techniques such as meditation will help, therapists could explore alternative neurodivergent-friendly mindful techniques such as those discussed by researcher Elliot Gavin Keena, Ph.D. Psych, himself living with autism, ADHD, and bipolar disorder, another form of neurodivergence.
A 2019 study explains that these methods include a grounding technique using your five senses, mindful stimming (self-stimulatory behaviors, usually taking the form of repetitive movements or sounds, that help many autistic people and ADHDers feel more calm and regulated), describing your experience, listening to music and even taking a break with a hot drink.
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7. Neurodivergent clients may need tools and methods made specifically for them
The most common complaint from neurodivergent therapy clients is that they wish therapists would stop telling them they are not trying hard enough. Instead, they wish therapists would figure out ways to make tools and methods neurodivergent affirming or suggest different methods.
“The basis of neurodivergent-affirming care comes from the neurodiversity paradigm,” says Megan Neff. “The idea behind the neurodiversity paradigm is that neurodivergent conditions like ADHD, Autism, Dyslexia, and others are normal variations in the human condition.” This approach recognizes that diversity helps humans as a whole to thrive and contrasts with the pathologizing medical model, which sees everything different from the norm as “something wrong” that needs curing or changing.
Rather, the neurodiversity paradigm views neurodivergent conditions as an integral part of the person. Trying to cure the person out of being neurodivergent is harmful to mental health and damages the person’s sense of identity. An example of this is pathologizing an autistic client’s special interests, says therapist Tania Glyde, who offers a list of resources for therapists to be able to more effectively and ethically support their neurodivergent clients.
Neurodivergent-affirming care “actively acknowledges the specific hurdles, barriers, and necessities faced by neurodivergent people,” says Neff. With this in mind, therapeutic strategies are customized to meet the individual’s particular circumstances, recognizing their uniqueness.
An article by Neurodiverging explained that approaches include incorporating the client’s interests and passions into the sessions to build rapport, affirming their neurodivergent identity, helping to address internalized ableism, and supporting them to explore taking care of their sensory needs, which have a fundamental impact on a neurodivergent person’s well-being. It’s key to be flexible in the techniques used and to offer alternative communication methods in sessions.
As more and more neurodivergent people come forward and speak about their experiences, the awareness picture is slowly changing. On-the-ground research is taking leaps and bounds, while more traditional research is still catching up. It’s vital that, in the meantime, therapists and other mental health professionals listen to what a range of neurodivergent people have to say about their experiences and needs so that they can support them better.
Ultimately, as with all therapy clients, the goal is to help neurodivergent clients accept their authentic selves and bring more of this into their lives. This can only happen when therapists understand their clients’ brain styles and what they need to thrive so that, in the words of neurodivergent affirming therapist Caitlin Hughes, they can feel “vibrant, neurodivergent, and unapologetically themselves.”
Morgana K. Sylvana is a writer, author, poet, neurodiversity advocate, and singer-songwriter whose articles have been featured in Wise & Well, Human Parts, and Psychology in Society, among others. Navigating life with autism and ADHD, she raises awareness about these neurotypes, busting myths and empowering others with validating self-knowledge.