When Therapy Harms Neurodivergent Clients

When it comes to autism and other forms of neurodivergence, a huge gap exists in our clinical education. In their new, two-part book, Is This Autism? Donna Henderson and Sarah Wayland report that 86% of healthcare providers in one study admitted they lacked the skills to treat autistic adults.

Clients can endure years of therapy thinking they are broken and getting "treatment" for the wrong thing.

There are two main ways autistic clients can be harmed in therapy. The first is by not getting a diagnosis in the first place because the therapist is not educated in non-stereotypical presentations of autism. The second is by the very nature of imbalanced power dynamics in the psychotherapeutic relationship and communication differences that can lead to therapeutic ruptures.

Lack of Diagnosis

When therapists are unaware that a client may be autistic and the client has never been diagnosed, therapists often attribute autistic traits to post-traumatic stress disorder (PTSD), anxiety, depression, or early childhood trauma. In reaching out to the autistic community, I heard story after story of years spent in therapy feeling like there was something wrong with them and never feeling understood.

One autistic woman, Chrysta Bairre, reported,

“By only focusing on my trauma, my lived experience as an autistic woman was overlooked, invalidated, and minimized, which reinforced many of my childhood experiences of being invalidated and minimized when I showed autistic traits and behaviors.”

Another woman was told by her therapist that there was no way she could be autistic and that she just needed to be more resilient and less sensitive.

When clients finally receive a proper diagnosis, there can be overwhelming relief that everything clicks into place. This is not to minimize the grief that can come with all the lost years of feeling chronically misunderstood and the missed opportunities for support and self-knowledge.

Josh Irby, an autistic man, noted, "Once I was told I was autistic, my life changed for the better virtually overnight. My suicidal ideation disappeared. I was able to come off medications. I no longer try to fix myself; I try to accommodate myself."

Sometimes, the diagnosis is just dismissed. One woman reported,

“My therapist told me I was 'emotionally stunted' and to 'stop obsessing' about having ADHD because it didn’t define me… when in fact it completely changed my life, connected me to people who understood, and furthered my self-understanding as a now identified AuDHDer.”

Harm in the Relationship

Power differentials are inherent in the therapeutic relationship. The more traditional psychoanalytic therapies are considered "one-person" models where the therapist is the authority and the holder of reality in the room. Any misunderstanding or disagreement is considered to be a projection on the part of the client and due to the client's pathology, while the therapist is an innocent bystander. This can create a dangerous gaslighting situation where the therapist doesn't take responsibility for their part in the rupture, and the relationship devolves into a victim or perpetrator dynamic.

Most psychoanalysts today practice from a more intersubjective or relational model, in which the relationship is considered "co-created." Even in this more egalitarian set-up, however, the client is always more vulnerable. For autistic clients who have experienced compliance training in behavioral therapy and traditional schooling, it can feel impossible to challenge the therapist's authority or even question it. Compliance trauma robs a person of trust in oneself.

Megan Anna Neff, an autistic psychologist and founder of the Neurodivergent Insights community, wrote a paper on inter-neurocommunication breakdowns. It frames the cross-neurotype therapeutic relationship through the lens of Jessica Benjamin's work, a psychoanalyst who coined the "doer-done-to" dynamic. This space is where two subjectivities cannot exist, and one person becomes the object. The "third" is the space where mutual recognition occurs. Without self-recognition (a proper diagnosis), mutual recognition is not achievable.

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A fundamental way in which therapists harm autistic clients is when the therapist does not acknowledge their ableist stance. If a therapist believes their "truth" is correct, any impasse in the relationship must be due to the client's pathology. As Neff says, "When therapists have not yet deconstructed autism narratives and worked through ableist and allistic-centered beliefs, they often re-enact doer-done-to dynamics with their autistic clients." Instead, therapists must conceptualize ruptures as occurring in the space between therapist and client. This gap is where the "third" emerges.

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What Is Neurodiversity-Affirming Therapy?

How can we, as neurotypical therapists, create a neuro-affirming space?

This begins with a mindset shift that steps out of a medical pathology model and trusts that autistic people are the experts in their own experience. As outsiders to the autistic experience, non-autistic therapists must practice "neuro-humility" regarding different experiences of neurodiversity.

For Katy Higgins Lee, a neurodivergent marriage and family therapist and neurodiversity educator, adapting the environment to the client's sensory needs is critical. If sessions are in-person, it may mean adjusting lighting, minimizing scents, and making sure the person feels free to move around and stim. If therapy is online, it means allowing the camera to be off if preferable and allowing again for movement breaks or stim toys, and especially not insisting on eye contact.

Creating a safe space involves transparency about the process, the "why" of what you are doing, and respecting the autonomy and goals of the client. This may also involve more self-disclosure on the therapist's part to ensure the client feels connected and safe.

Regarding technique, it is important to allow clients to talk about their profound interests. Autistic clients love to "info-dump" about things that are important to them, and this is a critical window into their internal world. It is not something to be interpreted or subdued.

Due to alexithymia, some autistic clients can have difficulty naming their emotions or labeling what is going on in their bodies. For many autistic clients, thoughts and emotions are intertwined. Rather than interpreting thinking as an intellectual defense, it's important for therapists to recognize that thoughts can be "drenched in emotions," as Neff says.

Asking typical therapy questions like, "How does that make you feel?" can be invasive and misattuned. These questions can make the client feel like they're doing therapy "wrong" and that they have to mask to give therapists the answers they're looking for.

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If therapists work more somatically, this can help clients notice what's going on in their bodies. Interoception is the "process of how the nervous system senses, interprets, and integrates signals originating from within the body" (Quigley et al., 2021). It is important to explain to clients that understanding their bodily sensations can increase interoceptive awareness, which is critical to a felt sense of psychological and physiological safety in the world. Interoception informs a sense of self and is key to self-regulation.

Finally, it is important to remember that we are not "treating" autism. So, what are we trying to achieve in therapy? Neurodivergent clients' therapeutic goals may constitute a greater ability to care for their nervous system and improve executive functioning skills. Therapy might involve clarifying needs and learning to self-advocate. A critical focus may be addressing a client's internalized shame about their neuro-differences and working toward a positive self-identity.

Most importantly, what is paramount is the therapeutic relationship itself. Embodying a humble therapeutic stance where one is fully open and curious to the experience of the other allows for a process of mutual discovery.