Neurodiversity Affirming Therapy & Autism Acceptance
by Nat Nigro, M. Ed., NCC (they/them)
Nat is a neurodivergent Nashville-based therapist specializing in neurodivergent-affirming therapy at Healing Umbrella Psychotherapy
Advocates in the autistic community have shared the importance of shifting from awareness to acceptance; people are aware autism exists, but autistic people need to feel truly accepted in our society. I would argue that even acceptance is not enough, and there needs to be more meaningful, tangible, and consistent efforts from allistic (non-autistic) people to accommodate and value autistic people and our community.
Many providers want to be affirming of their clients who have marginalized identities, but do not know how. There is not a clear definition or set of guidelines around Neurodiversity affirming care for autistic people, which can lead to confusion, misunderstandings, and potentially harmful experiences for clients. It is not as simple as wanting to be affirming and taking a class or course (even one that gives you a “certification”) - it is a complete paradigm shift in how we approach care, conceptualize our clients’ experiences including their challenges and goals, and a continuous commitment to learning. I will cover some basic principles of how (and how not to) approach therapy with autistic clients to hopefully encourage further efforts on an individual level to be more supportive of the autistic community. I will also discuss ideas for finding a Neurodiversity affirming mental health provider for clients as well.
What Neurodiversity Affirming Therapy is Not
Most clinicians want to be affirming and supportive of their clients. But what does that really mean when it comes to autistic clients? First, I’ll start with what Neurodiversity affirming therapy is not when it comes to working with the autistic community.
Beyond Not Overtly Disliking Autistic People
It is more than not overtly disliking or discriminating against autistic people. I hear many providers label themselves as Neurodiversity affirming, or checking that box on their marketing materials, but I also see them using terminology and describing approaches to working with clients that are fundamentally in opposition to being Neurodiversity affirming. I believe they want to be Neurodiversity affirming in that they don’t want autistic people to feel explicitly stigmatized and broken for being autistic, but this is simply the bare minimum for treating another person with respect and this is the minimum expectation I hold for every provider, regardless of if you label yourself Neurodiversity affirming or competent in working with autistic people. However, the standards of being Neurodiversity affirming are far above thinking your client is not broken because they are autistic.
More than a Strengths Based Approach
I also see many people align Neurodiversity affirming care with a strengths-based approach. While I see the good intention here in shifting from the deficit based framework of seeing being autistic as a list of problems to fix, it also closely mirrors the problematic nature of toxic positivity. Taking just a strengths based approach to any group that experiences oppression on many levels neglects and disregards the consistent harm that the members of the group experience. Being autistic in a neurotypical, ableist world is exhausting and traumatizing. I have had a significant amount of experiences being discriminated against and overtly harmed, while also experiencing chronic misunderstanding, infantilization, and other microaggressions on a regular basis. I also struggle with going to the grocery store and doing other seemingly simple tasks that many non-disabled people would not consider difficult. Taking a strengths based approach here completely misses all of the harm and challenges I have experienced because I am autistic in an unaccommodating world. Having a provider respond to me disclosing struggling with going to the grocery store with “That’s hard, but there are a lot of good parts about being autistic, like you know a lot about autism because it’s your special interest!” is not helpful at that moment. I know being autistic is not just negative, but I want someone to sit with me in the discomfort and challenges, rather than move on quickly to something positive. Autistic people deserve to feel seen in their struggles, while also getting support in making life more accessible. We deserve to feel validated in that we are not inherently broken or flawed, but to also be seen in the context that the world is legitimately a harsh and difficult place to exist.
These are two common, but not the only, misunderstandings when it comes to Neurodiversity affirming care for autistic people. When thinking about the components and principles of Neurodiversity affirming therapy for autistic people, there are a few central principles and concepts that come to mind for me.
What Neurodiversity Affirming Therapy Is
An Individualized Approach to Evidence Based Practices
Neurodiversity affirming care for autistic clients needs to be individualized. It would ultimately benefit everyone to approach therapy in this way, but it is especially important for Neurodivergent clients, including autistic clients. Mental health providers learn in school, trainings, and from other resources that are rooted in the pathology paradigm that evidence-based practices are the gold standard for helping our clients experience relief from distressing experiences. While there is great value in research and data, when we are thinking about evidence-based practices, we are thinking about modalities and approaches that were researched on predominantly white, cisgender, straight, neurotypical people. These are the people that responded (what the researchers deemed) “positively” to the evidence-based approaches. These approaches were not typically researched by or designed for autistic people. There is certainly still value to aspects of these approaches, but as a provider you must deeply understand what your client is experiencing, what is accessible to them, and what their goals are to decide what parts of these approaches might be helpful and most importantly how to adapt the specific skills or frameworks to work for the client in front of you.
For example, a common intervention, cognitive behavioral therapy, describes many cognitive distortions or unhelpful thinking patterns and labels these thinking patterns as maladaptive and inaccurate. However, for an autistic person who is repeatedly excluded socially and rejected in interpersonal relationships because they are autistic (or because people do not like their autistic traits), they may not be actually catastrophizing when something small happens during their day and they jump to the conclusion of “ah, the pattern is happening again, I am once again experiencing the harm of being disliked by my peers” because this may be a realistic read on the situation. Or, when doing EMDR with an autistic person, asking them to answer “what are you noticing” between sets of bilateral stimulation without any examples or more specific instructions/questions might be inaccessible to an autistic person as they do not intuitively know what kind of feedback the provider wants. So, it may be helpful to include an instruction like “I am going to ask you ‘What are you noticing’ between sets of bilateral stimulation. There is no right or wrong answer to this question and this could include a feeling in your body, an emotion you're noticing, a thought you're having, or a memory that is coming up.” These broad examples can make doing this part of EMDR more accessible to an autistic person.
Centering Clients’ Experience as Expert
Another important component of Neurodiversity affirming therapy centers around truly trusting your clients. Many autistic people, specifically late identified autistic people, do extensive research on autism - this is often out of necessity because they have been invalidated or disregarded from professionals who think they know their client better than the client knows themselves. Even if you see your client weekly for a long period of time, let's say an entire year, that is ultimately 52 hours that you spend with them out of the 8760 hours they have spent with themselves that year (not to mention all the years before they saw you!). There is so much that clients experience outside of therapy that your clinical impression or opinion may miss or even contradict and result in harm due to unchecked biases and assumptions or assertions of values. This is why it is so important to believe what your client is telling you. Do not minimize it or brush off their experiences or concerns. Especially when it comes to questioning if one might be autistic, I cannot tell you how many times I have heard from clients and friends (and experienced myself) that a provider's first response was “No you’re not autistic!”. Not only does that response invalidate your client’s experience and shut down any space for exploration and greater self-understanding, but it also is deeply rooted in ableism. Trying to reassure your client that they are not autistic is not a good thing because being autistic is not a bad thing. Discovering one is autistic is a complex, nuanced, and multifaceted experience. But ultimately, most late identified autistic people report it as a discovery that has an overall positive impact on their life and self-concept (this article discusses responses to late diagnosis in more depth). This common response from providers can be experienced as a rupture in the therapeutic relationship and because professionals don’t like to be wrong, it is also often not repaired. If this has or does happen, please take accountability and repair with your client. That in itself can be an invaluable relational experience that your client may not have had before especially with a person in a position of power. Trust, curiosity, and putting your instinctual responses to the side will help you better understand and support your autistic clients.
Helping Clients (Re)connect with Themselves
Many autistic people need therapy - but not for their autism. Autistic traits, or what many conceptualize as “symptoms” of autism should never be the focus of treatment. Autism is a neurodevelopmental condition meaning autistic kids will become autistic teenagers who will become autistic adults. You cannot change that someone is autistic even if you change their behaviors so they meet fewer of the DSM criteria. This just teaches autistic people that the way their body and mind want to function is inherently wrong, and to abandon their internal sense of knowing to do what others want. Teaching compliance is traumatizing. I spend extensive time in therapy with clients giving them space to welcome back in that sense of internal knowing and beginning to trust themselves again. Often people learn to mask and behave in a way that seems more neurotypical throughout life from subtle experiences of negative reinforcement when they are themselves (e.g. stimming or engaging in a special interest that may be seen as “unusual”) and positive reinforcement when they act in a way others expect of a neurotypical person. Masking is commonly explicitly taught to younger neurodivergent people in the context of teaching “social skills” or in Applied Behavioral Analysis, both of which are problematic. There are times and situations in which masking is needed for safety or one might want to choose to mask based on their goals or values or what’s important to them (e.g. for a job interview), but masking autistic traits should not be presented as a goal derived from an external source. Giving your client space to decipher what were things that they learned to do versus things that felt good for them can help them explore undoing that process of automatic masking, and reconnect with themselves. This process will likely also need to encompass breaking down internalized ableism that surfaces while exploring these learned compensatory and camouflaging experiences.
Support and Accommodations
Existing in our world is hard as an autistic person. Naming systems of oppression and the impact of them in your clients’ experience can be helpful in acknowledging that they are not the problem, but rather their environment is. But we must do more than just point out the oppressive world we live in. Support your clients in making the world more accessible to make their survival easier. This can be done through exploring systems of support, accommodations, and also practicing self-advocacy. When I mention accommodations, I do not just mean formal accommodations for tests at school or at work (although those are also important!). Accommodations can be anything that accommodates the needs of the individual better. This could be asking friends to use tone indicators when texting, wearing noise canceling headphones at the grocery store (or shopping online and picking your order up - a new one I am going to try), or requesting someone you’re comfortable with attend a social event with you and stay with you throughout the event to make navigating social interactions easier. When it comes to exploring systems of support and accommodations, use your creativity and think outside the box. What is your client finding difficult about the situation? Where is there flexibility and where is there not? What is most important to your client about this situation? Get curious and try to come up with ideas that can make life a bit easier for them. This also may take some trial and error.
An Expansive Understanding of Autism
This one seems somewhat obvious, but having knowledge on what autism looks like beyond the diagnostic criteria and narrow stereotypical understanding is imperative. This one is actually harder than it seems because there is not a designated straightforward training or resource to cover it all. Autism is complex and autistic people’s experiences are vast, but there are some common autistic experiences and experiences associated with autism that you can learn about. Being able to help your client link an experience in their daily life to shared commonalities within a broader community, can be incredibly helpful for helping us feel less alone and more deeply understood. If they know that their extreme difficulty with completing “basic” household tasks is due to PDA, then they can learn about PDA and figure out ways to make their life easier. Without knowing this though, they will likely be stuck in their struggle and the common ways to support or help them will likely not work (which will also probably lead to shame and other difficult feelings). The best way to learn about autism is from autistic people.
Unfortunately, most clinical trainings and other resources on autism fall short, perpetuating pervasive misunderstandings of autism and lacking conversation about the multifaceted nature of autistic experiences. Seek out books, social media accounts, websites, podcasts, etc. created by autistic people with diverse backgrounds and identities instead and provide these resources to your clients!
Some subtopics common within the autistic community include misophonia, PDA, camouflaging (often referred to as masking), alexithymia, meltdowns and shutdowns, the 8 sensory systems (especially, balance, proprioception, and interoception and how these differ for autistic people), ARFID, and autistic burnout (versus depression). I would also recommend looking into common chronic illnesses that the autistic community experiences, as there is a big overlap here and experiences associated with autism and chronic illness are intertwined.
Trauma Informed Care
Lastly, and I think most importantly, Neurodiversity affirming care for autistic people must be trauma informed care. And knowing that trauma exists and the symptoms of PTSD does not make you trauma informed. Trauma informed care is about autonomy, (continuous) informed consent, and dismantling the power dynamic in the therapy room. Autistic people (along with all groups that experience oppression on various levels) experience a lot of trauma. Much of this trauma is often complex trauma and relational trauma. Autistic people too often experience further relational trauma in the therapeutic relationship. This can look like being chronically misunderstood, assumptions being made about their experiences or intentions or needs, or being invalidated or minimized. Show up for your autistic clients and be willing to engage in repair when there is rupture in the relationship. Take accountability for harm that is done. Express and follow through on being committed to learning about your clients’ experiences on your own time (as this is not their job to educate you).
As mentioned before, autonomy and informed consent are also an important part of trauma informed care. Informed consent does not refer to the intake paperwork your client signed, and you maybe discussed at your first session. Informed consent means giving clear information on what the therapeutic process looks like with you, what is expected of them, ways in which they can revoke consent or discontinue therapy, and methods to provide feedback that have minimal barriers. Autonomy and informed consent look like explaining to your clients why you are bringing up a coping skill or suggesting a specific modality or approach and asking if they are interested in knowing more or exploring this further. It is giving your client sufficient information about what is happening in therapy and the various options for moving forward and allowing them to choose what would be best for them. And making it clear that curiosity and questions are more than welcome.
Trauma informed care in the context of relational trauma also means understanding that a client’s relational needs may be significant. These needs should not be pathologized. Autistic people are often told we are “too much”. You can set boundaries with a client without shaming or pathologizing their needs. For example, if a client is contacting you outside of session more than you are able to respond to, you do not need to force them to stop. You can acknowledge your limits and clearly articulate what you are able to give in this context, while acknowledging that ideally there would be better systems of support for them to get their needs met. You can also contextualize these needs to explain that as humans, we are meant to connect and exist in community. Especially in the context of disability or neurodivergence, we often have support needs that are unmet and that we cannot meet on our own. This does not make someone bad or needy or too much but is a reflection of a system that fails to provide adequate support for all members of our community. You can also help your client identify ways to meet some of these needs in an accessible way for them.
Conclusion
Providing Neurodiversity affirming care for autistic people is not innately complex or difficult, however, given the systems that dictate how one becomes a mental health provider, it is unfortunately difficult to find truly Neurodiversity affirming care as an autistic person. This is why we often seek out care strictly from people with lived experience - because there is a level of trust, safety, and understanding that comes from mutual experiences of oppression and harm. Because we know from our own experience what harmful approaches to therapy feel like and so we also know how to foster protections against them. There is so much space for allistic providers to learn more and grow into being Neurodiversity affirming and it is a much needed resource. But it does take a continuous commitment to learning (and unlearning) and decentering yourself as the expert.
For Autistic Clients - Tips for finding a Neurodiversity Affirming Provider
This search can be taught and exhausting. Here are some ideas of ways to decipher how affirming a provider is (because it is not a binary situation of being affirming or not, it is nuanced).
Questions to Ask a Provider
What is your understanding of the diagnostic criteria in the context of autism?
What you’re looking for: speaks to how limiting the criteria is and that it is not definitive or even close to all inclusive of autistic experiences; speaks to deficit based language of the criteria.
(specifically for allistic providers) Can you speak to your experiences of decentering yourself as the expert and taking accountability for when you may be wrong or do harm? Can you think of examples of times you have done this professionally and personally?
What you’re looking for: them doing this regularly, and acknowledging this is a consistent practice especially when they do not have lived experience.
What is your understanding of the Neurodiversity Movement? What about Mad Pride, the Hearing Voices Movement, and Disability Justice? What do these mean to you in the context of providing mental health care? How do you integrate the principles of these paradigms into your work?
What you’re looking for: a solid understanding of the neurodiversity paradigm and awareness of other movements; acknowledging that mental health care is deeply rooted in the pathology paradigm; tangible examples of them altering the way they approach care to move away from the pathology paradigm towards a neurodiversity paradigm.
Who are the people you look to for information on autism?
What you’re looking for: being able to name or reference trustworthy autistic advocates and educators (it is ok if they cannot recall people by name, but they should know who they are in some way/shape/form and be able to easily access and locate their profiles/information); a variety of other identities within this group of people (i.e. BIPOC, physically disabled, multiply neurodivergent, various class backgrounds, etc.) and centering those who are most impacted.
What is your understanding of masking?
What you’re looking for: understanding that masking is taxing and takes spoons; acknowledging that masking is sometimes or often necessary to survive (especially for multiply marginalized people), and can be a helpful skill/privilege should one have the ability and spoons to mask; knowledge on ways to practice unmasking if applicable; knowledge on ways to foster care and rest after situations where we need to or ultimately decide it is in our best interest to mask.
What does trauma-informed care mean to you? Can you speak to how you integrate this into your practice?
What you’re looking for: centering autonomy and informed consent; ways they integrate this into their practice daily or at a fundamental level.
What do you see as included under the label Neurodivergent?
What you’re looking for: a variety of ways brains can diverge, not just Autism and ADHD and learning disabilities. (Helpful graphic with many examples)
What are ways that you can accommodate various sensory or communication needs in session?
What you’re looking for: examples of ways to adjust the environment to meet needs like lighting, scents, sounds, fabrics, seating options; options to use AAC rather than strictly communicate with mouth words; inquiring about anticipated needs and offering to adjust any other needs that come up to make you more comfortable and the space/process more accessible.
Cues to look for
There is nuance here in that one does not need to do all of these things to be affirming. These are just cues that are often associated with being affirming that you may see in their marketing materials, profiles, or in consultations. The more cues you pick up on, the more likely the person is to be affirming. But not doing one of these things does not automatically make someone not affirming - instead of writing people off, I would invite them to share about their thinking behind this to get more information. Additionally, these reflect the preferences of the autistic community more generally, and some autistic individuals may use different language for themselves - always use the language the autistic person prefers.
Using identity first language rather than person first language (supporting article)
Using the terms “neurodivergent” and “neurodiverse” correctly (explanation)
Cites autistic advocates and educators as resources. Does not cite autism speaks as a resource. (explanation)
If they use symbols on their website/marketing, it is a gold or rainbow infinity symbol, not a puzzle piece. (explanation)
Refers to autism as autism (or other non-disordered language) rather than ASD/autism spectrum disorder (because it is not a disorder).
Does not use Neurodivergent as a euphemism or synonymously with Autism/ADHD. And similarly, do not use neurotypical synonymously with allistic. (You can see throughout this article, I was very intentional about my use of Neurodivergent versus autistic and neurotypical versus allistic. When I said neurodivergent, I really was referring to the concept of having a divergent mind, and when I wanted to refer to autism, I said autism/autistic.)
