Therapists, are you harming your Autistic and ADHD clients? (PART TWO)

Photo by C D-X on Unsplash

Part 2/2: Negative outcomes, what you can do to avoid them, and some further resources

You’re likely here because you’ve read my previous post, ‘Therapists, are you harming your autistic and ADHD clients? (Part One)‘ and are interested in reading more. If you’ve just stumbled on this page, I recommend you check out Part One first.

Part One received a lot of support and resonated for many people. In response one person noted that, when handled effectively, silence can also be a positive thing for the autistic or ADHD client, as it allows time for differences in processing speeds. Someone else reminded me that supervision can also be a challenging environment for the ND therapist. Along with harm in therapy and harm in training, it feels like our industry needs to examine its approach to harm in supervision.

I know there’s a lot of talk of harm here, of damage, but we need to look deeply into this before we can start to build something better for our industry, for ourselves, and for our clients.

Of course, we’re therapists so we know that everything can be flipped on its head and reframed. And lateral thinking can absolutely apply. There may be moments where some of the interventions I describe in Part One, between a sufficiently attuned therapist and their safe-enough-feeling client might, in a particular moment, be okay and helpful. But we cannot count on it.

PLEASE NOTE

• This post is not a primer about autism, ADHD or any other form of neurodivergence.

• Please note that Autism and ADHD often co-occur, so you will see people increasingly describing themselves as AuDHD.

• The list of resources at the bottom is a starting place, an invitation to deepen your knowledge and find greater understanding.

• I do not endorse every word ever written by anyone I list here, or on the websites where these posts may appear.

• A list of red flag words, expressions, names and media output that you would do well to take care around is unfortunately beyond the scope of this post. [anyone?]

So what might the outcomes of harmful therapist behaviours, (however unintentional), be for the autistic and ADHD client?

(1) In one-to-one therapy

(a) The client leaves therapy without being helped.

Actually, simply not being helped may be the least harmful outcome. Someone may end up feeling as if this ‘failure’ was all their fault, confirming their sense that they are defective, broken, and beyond help. The therapy may have replicated how they have already been treated in other contexts.

(b) The client leaves therapy, never to return.

Their trust in people may already have been low – now it will be lower. Their internalised stigma may also increase. They may feel that getting support is just not worth the effort.

(c) The client remains in therapy but evolves strategies for pleasing the therapist.

This is of course no help to the client, but again they may be playing out a scenario familiar from the rest of their life. They mask in sessions and evolve ways to please the therapist by, for example (as I described in Part One), staring at the therapist’s forehead, or tolerating discomfort in the therapy room such as non-optimal seating arrangements, or tolerate amusement or judgements from the therapist about talking too much or getting angry about injustice, or wanting to stim. Ultimately, while this therapy might produce something positive, overall it will simply reinforce the status quo.

(d) Remember that the suicide rate is higher in autistic people and people with ADHD than in the neurotypical population.

The first of the two studies I link to there also highlights the presence of undiagnosed autistic traits in those who died by suicide. I wonder, in fact, just how many undiagnosed neurodivergent people attempt suicide. Perhaps they got labelled with ‘anxiety’ or ‘depression’ without anyone looking further, because they weren’t presenting like a ‘naughty little boy’. It is for this reason, on top of many others, that therapists need improved professional competence in this area.

(2) What happens to the parents of neurodivergent children (who may well be neurodivergent themselves), when accessing therapy and support?

Although these two posts do not focus on the specific experiences of children and young people, it’s worth looking at parents’ experiences when trying to get help – for themselves and their child. The original group discussion was particularly full of frustration and anger on this subject. It deserves a whole article on its own.

(a) Back we go to attachment theory!

This seemed almost a rite of passage for a parent trying to seek help for their child from local authorities. They would be labelled ‘enmeshed’ and pathologised as having ‘attachment issues’. Social workers, teachers, and therapists, (etc), may tell parents they are ‘overprotective’ of their children, or label someone an ‘anxious mum’ who is overreacting and ‘attention seeking,’ when the reason for them appearing to be this way is that they have had to fight for their child since they day they were born. This seemed particularly the case when the child had already been bullied or ostracised at school.

(b) Parents being accused of FII (Fabricated or Induced illness) to get their child some attention. 

Given the existing scarcity of local authority resources, it is sadly unsurprising that those with the job of gatekeeping are going to try to find ways to keep people out of the system. But seriously?

(c) The mental health impacts of fighting the system.

The stress of this for the parents, and the impact on the child or children, may drive parents and whole families to burnout. This may then itself then be pathologised by gatekeepers as ‘inability to cope’. Also, as neurodivergence runs in families, these parents may be neurodivergent themselves, so they may be doubly struggling. The judgments inherent in these attitudes and the battle for basic services simply cause more stress, anger, guilt and shame for the parents which may in turn impact the child. (It is worth reading about the history of autism and the outdated idea of the ‘refrigerator mother’.)

(d) A reminder that the system is set up to be adversarial.

Just like the benefits system, the social support system seems designed to tire people out so that they either give up and go away; submit to whatever they are being told to do; or react strongly negatively which will then ‘justify’ rejection or disqualification from support or benefits, or sanctions.

(3) What about neurodivergent therapists who are being managed or trained by other therapists?

The experience of ND therapists is a whole other topic which needs a separate post. There are a lot of us around.

(a) Neurodivergent therapists may struggle in the workplace.

Their managers may assume that all ND therapists need the same workplace accommodations, and then may react badly when the therapist asks for something specific, such as no scented products or loud clocks in shared therapy rooms.

(b) Neurodivergent trainee therapists are likely to be treated differently.

Even if someone has a diagnosis, they may feel self conscious about asking for accommodations. If self-diagnosed they may have to debate this and struggle to be taken seriously. If the trainee is undiagnosed and unaware of it they may experience all sorts of unowned poor treatment from their training organisation.

Systemic factors

It is important to reflect on where patriarchy, colonialism and the medical model collude to influence healthcare systems and public understanding, causing neurodivergent people (and their children) to be seen as annoyances and anomalies.

Many gender variant people are neurodivergent, (and many GSRD identified people as a whole). If a therapist is not sufficiently aware of GSRD identities (and worse, holds prejudiced views about them), the likelihood of damage will be greater. Similarly, for example, in the case of a white therapist working with a client of colour who is also ND.

‘Oh gosh! We’re back at identities and labels again! Can’t we get beyond this, just for once???’

When people speak, you need to listen (which is kind of what therapy is about, no?). When a whole group of people speaks, who are united by a particular identity (or label), you need to listen extra hard, particularly if you are a therapist! This needs to change at root level, which means from training organisations who provide primary trainings upwards.

Therapy has traditionally been framed by patriarchal, white western thinking. I don’t necessarily say ‘throw it all in the bin’ (not all of it anyway) but it simply isn’t questioned enough from within. There is no getting away from this. It brings a top-down aspect to therapy which can engender harm (‘therapist knows best’), and a lack of consent. If you are working as a therapist, you need to keep the ultimate consent question perpetually in mind: ‘Who is this for?’

Equally, the ‘I don’t judge’ approach sounds nice on the surface, but it is clear that if a therapist doesn’t have a good handle on GSRD, (or race, or in this case autism and ADHD), as soon as they hcome across something they have no handle on, they are likely to do exactly that. Ditto ‘I just want to help people’ – your saviourism may also do harm.

What to do next

What you need to do now is check out the people who are talking about this publicly and LISTEN TO THEM. Listen to autistic people and ADHD people and all neurodivergent people who have been in therapy and had a negative experience – or a good one.

Particularly if you are in middle age and older, go online and read what younger people are saying. A lot of people are out there putting a lot of time into explaining their lived experience in the public sphere. That is where you will find current thinking on all this.

Some older therapists maintain a lofty distance from social media and therefore from social trends. This will not help your practice. If you cannot be online much, then talk to younger people. But please don’t use your younger clients as resources!

You can also attend one of the many trainings that are available. (See below.)

‘So are you saying we should treat our neurodivergent clients like helpless little snowflakes??’

Here we come to the central issue. If therapists and their trainers mainly come from a homogenous and privileged group with little experience outside that group, they will assume their knowledge, experience, resources, and levels of resilience are the same for everyone else in society. This of course is not the case.

Remember, it is labour for a client in therapy to challenge and correct their therapist, especially when they are not sure what they are challenging them about. It’s easy for a therapist to say ‘But that’s the work, isn’t it?‘ I mean, sure, yes, in an ideal world! But there has to be trust. And if you as a therapist don’t work on your cultural competence, you are creating extra work for your minority and minoritised clients – clients who are already likely to be exhausted from navigating similar scenarios in the rest of their lives. It’s not your job to make this harder for them.

Work towards changing therapist trainings from the inside

I keep mentioning primary qualification trainings (ie Diploma, PGDip, Masters) because the way the trainers model the work will be replicated by the therapist in the therapy room.

A central issue here is the learning edge. This is the place, that is not too comfortable but also not too stressful, where we are especially open to taking in new experiences. Trainers aim to take us to this place and hold us there for just the right amount of time for us to benefit and take in the information.

But the learning edge is not a rigid boundary like a circle or square, along which everyone will have the same experience. In fact, everyone’s learning edge is different. Any individual’s learning bandwidth is going to be wider or narrower depending on many factors. One size does not fit all.

Once again, I hope this is helpful.

Resources

Below I have frankly infodumped some links. I have not read every word of everything here. If you know any good ones please tell me and I will add them – or if you think any of these are terrible.

You will notice the skew towards autism. This is due to the nature of my own existing resources. However, the more I learn, the more I find that the map of neurodivergence is a closely knit Venn diagram rather than, say, a flower. As I said above, a significant number of people with autism also have ADHD, and a fairly high number of people wth ADHD are also autistic. Hence a number of people calling themselves AuDHD. There will be much that is relevant here for many people.

Autistic and ADHD clients in therapy – experiences

• Therapy & Neurodivergence

• Autistic Adults Experiences of Counselling

• Autistic people should not have to educate their therapist

• An Autistic’s Vision for Neurodiversity-Affirming Therapy

• Neurotypical psychotherapists and autistic clients

• Autistic Therapy: 8 Things to Consider

Research and media

• ‘Autistic while black’: How autism amplifies stereotypes

• Barriers to healthcare and a ‘triple empathy problem’ may lead to adverse outcomes for autistic adults: A qualitative study

• Black adults who live with ADHD

• Counselling Clients with ADHD

• ‘Living in a world that’s not about us’: The impact of everyday life on the health and wellbeing of autistic women and gender diverse people

• ’No you’re not’ – a portrait of autistic women

• Race and ADHD

• Silver linings of ADHD: a thematic analysis of adults’ positive experiences with living with ADHD

• The lived experiences of adults with attention-deficit/hyperactivity disorder: A rapid review of qualitative evidence

CPD TRAINING ORGANISATIONS

• Free2BMe, Neurodiversity training, specialist neurodivergent support

• Vanguard Neurodiversity Training

• Aspire Autism Consultancy

• The Autistic Advocate

• Reframing Autism – Autism Essentials

• Aucademy

PEOPLE TO FOLLOW ONLINE

There is a very large number of ND influencers who are producing a lot of content, particularly on Instagramand still on Twitter (X). This is a small selection and I have undoubtedly missed out some good ones.

autistic_callum_ (Tw and IG)
neuroclastic (Tw and IG)
neurodivergentrebel (Tw and IG)
autienelle (Tw and IG)
neurodivergent_insights (Tw and IG)
neurodivergent_researcher (IG)
autisticflair (IG)

annmemmott (Tw)

DrRJChapman (Tw)

• AJ Singh / AJ Singh LinkedIn

• Black Girl Lost Keys / @blkgirllostkeys

• Leanne Maskell

• Neurodivergent Rebel

• The Thoughtspot: How being autistic is linked to ego death

BOOKS TO READ

• Edward M Hallowell & John R Ratey ADHD 2.0 New Science and Essential Strategies for Thriving with Distraction – from Childhood through Adulthood

• Eva A Mendes & Meredith R Maroney Gender Identity, Sexuality and Autism: Voices from Across the Spectrum (Foreword: Wenn Lawson)

• Anand Prahlad The Secret Life of a Black Aspie: A Memoir

• Devon Price Unmasking Autism: The Power of Embracing Our Hidden Neurodiversity (also on Instagram)

• Bianca Toeps But you don’t look autistic at all

• Pete Wharmby Untypical – How the World Isn’t Built for Autistic People and What We Should All Do About it (Also on Instagram and Linked In)

Therapists, are you harming your autistic and ADHD clients? (Part One)


Photo by Sid Verma on Unsplash

Part 1/2: Assumptions, Interventions, and When Good Intentions Go Bad

This post comes out of an online discussion involving a number of therapists who work with neurodivergent (ND) clients, many of whom are themselves ND or are parents of ND children. There was a lot of frustration expressed. I have summarised the discussion here and added some thoughts of my own.

I sense a wave building around this topic. Personally, it’s helping me crystallise some of the thoughts I’ve been having since long before I trained as a therapist but, until recent years, I was not able to name.

Why am I interested in this?

I am late-diagnosed ND. This has been highly impactful. As a previously undiagnosed ND client in therapy, I found myself on the receiving end of some of what you read here. And before I found greater understanding, as a therapist I may have also enacted some of these things myself, or at least believed in them. 

PLEASE NOTE 

• This article cannot be exhaustive, and cannot be a full-on explainer – it could easily be a long form essay or a book – but I hope it will be a conversation starter. In part two I will link to further resources.

• The main focus of this post is on working with adults rather than children.

• The online discussion focused mainly on autism, ADHD and AuDHD, so those identities are the priority here, but the neurodivergent umbrella (which covers both developmental and acquired neurodivergence) is way more expansive. However, many of the scenarios I describe here could apply across the board.

• If I have linked to an article on a particular website, it doesn’t mean I agree with everything else on that website.

• For brevity I will often be using the acronym ND in this article, short for ‘neurodivergent’ or ‘neurodivergence’. (NT = neurotypical).

‘Wait! You can’t be talking about MY modality, surely?!’

If you are a therapist reading this you may already be feeling on the defensive, so please give yourself some time. And, actually, there is no need to descend into modality wars – because there is literally no therapeutic modality that cannot be used harmfully with a neurodivergent client! 

Any therapeutic modality (as well as the therapy world itself) may become ossified without constant self-reflection and consideration of the shifting social context as well as increasing awareness of neuro difference. For example, out in therapy land you will find folks who believe that, for example, Unconditional Positive Regard and Attachment Theory, are immutable concepts like the sun rising again.

Also – and this is really important – a lot of therapy research has been carried out by, and with, white neurotypical people, which potentially limits their value to many. 

Much of what I’ve written below fits within the contemporary definition of gaslighting. The word has come a long way since the old movie, Gaslight. In essence, it’s about misusing power over another person by telling them that they don’t know their own mind. 

This list is long. I’ve laid it out as simply as possible.

ONE – RIGID ADHERENCE TO MODALITY

I go into further detail in the sections below, but here are some obvious ones:

(a) Being determinedly non-directive despite the client needing, and requesting, structure and clarity. 

(b) Not answering direct questions from the client without going into a whole ritual dance of ‘I wonder why you are asking that’ first is often unhelpful. [This is similarly unhelpful when a client is also GSRD (Gender, Sex and Relationship Diversity) identified and may welcome a therapist explaining or disclosing.] Psychoeducation is valid and may bolster a client’s sense of autonomy. For example, if someone is having issues at work, they may need help to understand the covert meanings of what is going on, and so start to protect themselves from power games played by colleagues. A client may feel abandoned if the therapist does not support them when they ask about something.

(c) Therapist silence can be highly detrimental. The inherent slipperiness of the blank screen technique can simply be torture to an autistic client who may be seeking rules to work by, or an ADHD client experiencing RSD (Rejection Sensitive Dysphoria).

(d) Relying on specific jargon, eg ‘splitting’, when the client shows strong emotion; or if they are talkative, being told this is ‘ego defence’ or ‘resistance’. (The irony of this rigid adherence may not be lost on an autistic client who may have previously been criticised for their ‘rigidity’.)

(e) CBT-style thinking: No one (ND or not) should be encouraged to see their thinking as defective, and be encouraged to change their behaviour as if they are the one at fault, when the issues are likely their environment and lack of accommodations.

TWO – THERAPIST ASSUMPTIONS

(a) ‘Of course it’s not autism or ADHD – it must be trauma!’

Being autistic or ADHD does not mean the person is automatically traumatised. But due to the way ND people are often treated from a young age, they are very likely to be traumatised because of this. Being either diagnosed and stigmatised, or living undiagnosed and spending life thinking they are defective or useless – that for sure is trauma.

(b) ‘Of course it’s not autism or ADHD – It must be attachment issues!’

There was particularly pronounced anger in the group about this, particularly from parents of ND children. I go into more detail on this in part two, on negative outcomes. There are many critiques of attachment theory and it is not an immutable law.

(c) ‘Isn’t this client just avoidant?’

The alleged avoidance may actually be alexithymia. Lack of ability to name feelings is one reason why an ND 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. Also, when you have been stigmatised because of who you are, you may well have learned to hold back as an aspect of masking, for safety.

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.

(d) Assuming deficits rather than differences

Using the medical model of cognitive or behavioural deficits, while not understanding, say, sensory processing differences or monotropism, is not helpful, and neither is assuming the client is broken or disordered and needs fixing. The therapist may rigidly adhere to the DSM, which assumes a deficit model. The therapist may try to get the client to change or deny their ND characteristics, and when this doesn’t work the ND client leaves feeling broken (see part two). This will not help a client work on undoing the internalised ableism they are likely experiencing.

(e) Not understanding the autistic sense of injustice and moral injury

‘I can’t understand why you’re still angry about that!’ It is infantilising and frustrating when a therapist regally waves away a client’s lingering sense of injustice. (Poorly held therapy may of course incite this feeling in the client also.) This may be compounded by the power dynamic between therapist and client, highlighted by, for example, gender, race or class differences.

(f) Assuming the client is ‘nervous’ or ‘anxious’ 

It’s important not to assume the client is nervous just because they are stimming in various ways, or they are talking a lot about special interests, which a therapist may dismiss as ‘obsessions’. Also many ND people may process what’s going on for them out loud and rapidly in a way that may seem over detailed, or a distraction, to a therapist who is not aware. If a client talks fast this may just be how they talk, rather than a sign that they are stressed and need to calm down.

(g) Infantilising the client for their ‘compliance’

A client who pays on time and turns up on time may be held to be ‘compliant’. This in autistic people may be viewed as something childlike or even negative rather than cooperative.

THREE – UNHELPFUL INTERVENTIONS

(a) ‘You’ve got to make them feel the feelings!’

Many ND clients are already feeling a lot of feelings and a therapist pushing them to feel more will not be therapeutic. Ditto the technique of goading the client into anxiety or anger in order to get them to have the feeling again in the ‘safe space’ of a transferential relationship in the therapy room. 

Also, 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. 

(b) ‘Let’s do some meditation!’

Speaking as someone who experienced the query ‘Have you tried meditation?’ many times in a therapeutic context, there are actually many people who cannot sit still and focus inwards, and for whom this may be actively detrimental. Focusing on the breath or doing body scans (see below) may be traumatic and bring up bad memories. In fact, meditation can be anything you want it to be, eg dancing or cleaning, but this is rarely pointed out. When I explained that traditional meditation methods did not work for me, there was often an implication that I just hadn’t tried hard enough, which is often directed at ND people.

Similarly with guided visualisations – someone who is aphantasic or hyperphantasic may struggle.

(c) ‘Let’s do a body scan!’ or ‘Let’s explore your bodily felt sense!‘

Many ND people struggle with interoception and may be unable to access what is apparently being asked for. Also, someone with sexual trauma (of which there is a higher than average incidence among autistic girls and women) may find themselves going into a fawn (compliant) response when asked to do things with their body, which will leave them feeling worse afterwards.

(d) ‘Why aren’t they looking me in the eye? I need to do something about this.’

The therapist may interpret a client not looking them in the eye as denial, avoidance or dishonesty. Actually, eye contact is not the universal positive this would seem to imply. In many cultures it is seen as disrespectful to look someone in the eye, particularly someone in authority. Some ND clients who struggle with eye contact will simply evolve a way of staring at a point on the therapist’s forehead and hope that it’ll do – thereby distracting them from the work.

(e) Pathologising a client being late for sessions

Again this is treated as if it must be avoidance, when it may be executive functioning or memory. Some people with ADHD really struggle with this.

(f) Pathologising a client’s special interests

Someone might have an aspect of social justice or any kind of politics as a special interest. If this makes the therapist uncomfortable this is for them to work on.

(g) Expecting homework tasks to be completed

Many clients struggle with homework for all sorts of reasons. Making non-completion (non-compliance?) a thing may add to client stress. There may also be echoes from challenging schooldays here, as well as the impact of PDA (conventionally known as Pathological Demand Avoidance, but also known as Pervasive Drive for Autonomy).

(h) Suggesting the ND client has a personality disorder or other pathology

While this takes us closer to psychiatry, it’s still worth remembering that ‘personality disorder’ as an idea is often used harmfully, and the diagnosis of BPD/EUPD is often used stigmatisingly against young women, queer and trans clients, People of Colour and ND clients when, ironically, it is often trauma that is manifesting. Similar applies when suspecting the ND client is a ‘narcissist’.

FOUR – WHEN GOOD INTENTIONS GO BAD 

(a) Not raising the possibility that a client may be neurodivergent

Generally clients are open to hearing this. Yes, it has to be done with care as most therapists are not qualified to diagnose – but it can absolutely be explored. But withholding this possibility may cause harm to the client in the long run. 

(b) Not wanting to label the client

Following on from the above, some therapists cling to the idea of ‘Why do we need labels?’ [See also: working with GSRD clients] and it generally comes from a place of privilege (or structural social advantage). This may cause them not to suggest a client may have ND traits. Actually, labels help people find their peers and make adjustments to their lives where they can, and feel as if they aren’t going mad. This can also help prevent burnout from trying to survive in a neurotypical world and keeping up with neurotypical peers.

(c) Normalising the client as a therapeutic goal

A therapist’s goals may be to make the client fit better into society. This may come from a place of good intention, by wanting to rescue the client from their struggles. However, this is likely to result in the client masking even further, on top of what they are already doing. Therapists need to understand ND masking rather than pathologise it. 

(d) Assuming that the client always has the answer

This may appear to contradict some of what I am saying, but sometimes the client does not have the answer because they may not be aware they are autistic or ADHD and so may not have the answer that needs to be voiced. Open-ended questions may not always be helpful here.

(e) Assuming that all ND stereotypes apply to all ND people

Such as: Autistics have no empathy and are good with numbers; ADHD people are lazy and lose their keys all the time and can’t sit still. Assuming all ND people are the same does not help. For example, autistic people are often hyper-empathic and this contributes to many challenges of burnout and sensory processing. 

(f) Therapist has previous knowledge about autism but their knowledge is outdated

This is why many autistic and ADHD people refuse to engage with trainings, seminars or research where those teaching or writing are not autistic, ADHD or otherwise ND themselves. Also, some organisations/individuals are still promoting ABA (Applied Behaviour Analysis) therapy which is held in very low regard in the autism community.

(g) Lack of understanding of the Neurodiversity Paradigm

This may manifest as dismissing neurodivergence as a ‘young people with green hair on the internet thing’. [See also therapist’s attitude to gender variance; and there is a high correlation between gender variance and neurodivergence.] The therapist may infantilise a client who wants to explore themselves, or try to debate them either about the diagnosis they have received, or their self-diagnosis. Another issue is not understanding why a person might choose to self diagnose, or why they may have no option otherwise.

(h) Issues in the therapy room or when working online

A practitioner may think they have made their therapy room more inviting, but this is not necessarily the case. Bright fluorescent lights, ticking clocks, scented air fresheners, flickering lights or candles, insisting that the client remains sitting still in their seat and that the seat is directly facing the client, may all cause stress. Online, insisting the client is not lying in bed. [I’m also aware of challenges to this – that sometimes changing position can be helpful.] Insisting that the client leave their camera on.

CONCLUSION TO PART ONE

I can hear many theoretical objections to the above already! But remember this is real examples from real people we are talking about. Other ND folks may have had better experiences than the above, and there is no perfect therapy.

In part two [coming soon] I am looking at negative outcomes, suggestions of what you can do next, and a list of resources.