Counselling in a Neurodiverse World
This piece was originally written for and delivered at the National Autistic Society Annual Professionals Conference in March 2024.
Linguistic note: When I say ‘neurodiverse’ here, I’m referring to the diversity of all ways of being in the world, including those who are more neurotypical, those who have named neurodivergent identities such as autism and ADHD, and those who are neurodivergent in more uncategorised ways. Neurodiversity *is not* an alternative way to talk about autism, ADHD, Tourettes, or any other way of being neurodivergent. It is a quality of groups, not individuals.
Some years ago, I worked with AMASE, the Autistic Mutual Aid Society Edinburgh, on a piece of research and report, looking at autistic people’s experiences of mental health support in Scotland. The Too Complicated to Treat report and project not only found that autistic people were being systematically turned away by mental health systems, but also that when we did access support, such as therapy, it was often inaccessible, or involved practitioners with inadequate knowledge of autism, and working with autistic people.
Following that report I collaborated on another piece of research on autistic people’s experiences of talk therapies, which drilled deeper into what was happening for autistic clients in counselling rooms — both what went well, and what went badly.
This left me with a burning question: ‘What’s happening in counselling training that is leading so many autistic people to have such poor experiences of therapy?’ This is what led me to go into counselling training myself, and which, slightly to my surprise, led me to realise that I really wanted to become a therapist.
These days I work almost exclusively with autistic and ADHD clients, many of whom are also queer, particularly trans, and have other disabilities or neurological differences. I also support neurodivergent counselling trainees, as counselling training can unfortunately be an extremely unforgiving place for people who are different, and I benefited hugely myself from the support of neurodivergent mentors and supervisors in surviving my own training.
All these experiences, as well as my own personal therapy, have led me to the conclusion that one of the big problems facing therapy today, in terms of its lack of accessibility, suitability, and potential to do harm towards people who are different, be they neurodivergent, queer, disabled, people of colour, or a combination of all the above, is a lack in diversity in the ways we envisage therapy.
What therapy looks like right now is largely a monoculture, despite the many different modalities, proliferation of EDI training and CPDs on neurodiversity, queerness, race, etc.
Let me diverge into an analogy for a moment to illustrate my point. I want you all to take a moment, and picture a park in your head.
How many of you pictured a park with grassy lawns?
Lush neatly mown green lawns are such a normal everyday sight for a lot of us that hardly anyone questions it — but that is a monoculture, and a tightly controlled one. There are whole aisles in garden centres dedicated to lawn care — products that maintain this monoculture, kill weeds, remove bugs, keep grass tidy and short and the right shade of green. Of course, lawns can be lovely to sit on, freshly mown grass smells delicious, and for many of us might be familiar and evocative of summer picnics, kicking a ball or throwing a frisbee. I’m not saying there couldn’t be a place for lawns.
But when we get too used to seeing monocultures, we forget that there can be anything else. We don’t notice what is being pushed out in favour of the familiar sameness we have gotten used to. Diversity becomes worrisome and weird and unfamiliar.
Now, I’d like you to try and picture a person in a therapy session.
I wonder what you pictured. I wonder how many of you pictured two people sitting opposite each other in a room, a little table in the middle, a tissue box, neutral wall colours, a clock, maybe a plant in the corner?
What if the things that feel familiar and comfortable to us in counselling, what counselling looks and feels like, how we are as therapists or related practitioners, what if they are also reinforcing a monoculture? Who and what ways of being have we unconsciously made unwelcome in our spaces?
When we published the Too Complicated to Treat and Autistic People’s Experiences of Talk Therapy reports, I spent a lot of time looking at and drawing up recommendations around the types of practical things that can help make counselling more accessible for neurodivergent people, and I do encourage you to look them up. They are things like: the lighting, can it be adjusted? Could it be flickery or too bright? Are there distracting sounds from other rooms and could there be quieter waiting areas? Could the seats be angled at 90 degrees rather than facing each other for clients who don’t like direct eye-contact? Could clear written instructions about the procedures be provided — about arrival, cancellation, payment, contact between sessions, etc? Are there alternative options to phone contact? Could fidget objects be provided? Could sessions be longer or shorter? Or occur more or less frequently? Or be outdoors?
I noticed when I ran talks and trainings on this theme that therapists would often write down these suggestions — and I do think it can be helpful to have practical ideas for how to adapt our ways of working, but I think what I was starting to get at was the sense of therapy being potentially a very different shape, a very different animal, when working with different individuals.
I don’t see these ideas as being ‘accommodations’ or ‘adjustments’, because they shouldn’t ideally be tacked on to a normative way of working in therapy — I’m not suggesting that we just add a small wildflower patch to a lawn for the bees. I’m suggesting that sometimes, we need to dig up the whole damn lawn.
I don’t mean by this that we throw out all the important principles of safety, ethics, containment, and so on, that are needed in therapy. Instead, I’m suggesting that too often we can end up relying on the shape of therapy looking familiar to imply that it is indeed safe, ethical, contained, when in fact it might not be for clients with divergent needs and experiences, just as we might think of a park as safe because it has clearly defined lawns and paths, because the grass is short and the layout is familiar, but we are only starting to understand the damage that these tightly controlled spaces could be wreaking on biodiversity. When I talk about digging up the whole damn lawn, I’m inviting you to really dig into your expectations around therapy, mental health, recovery, emotions, communication, connection and all these related concepts.
Autistic people I’ve encountered in all kinds of contexts, as well as respondents in our research, have talked about their struggles with the pressures and expectations of therapy. There can be an immense sense of pressure, especially in time-limited therapy, to dig right into sometimes deeply painful experiences that our monotropic processes might find hard to put down again from week to week, leaving some in a constant and unbearable state of crisis. People have talked about not having time to settle in and get a feel for what they need, and whether the space and therapist is safe enough. People talked about their experiences of being neurodivergent in a neurotypical-dominant world not being understood, or being minimised or invalidated. People talked about feeling like they were failing at therapy because they weren’t able to use the types of emotional vocabulary the therapist expected, or they were seen as ‘not engaging’ for not being interested in expected ‘positive outcomes’ such as becoming ‘more outgoing’. People talked about having to educate their therapists about autism and neurodiversity, or feeling a pressure to make the way they communicate more linear to cater to expectations around ‘getting to the point’ or following a singular narrative.
To me, all of these are examples of ways in which the therapist might not have been meeting the autistic client half way, leaning back into the norms of therapy and leaving too much up to the person coming to therapy to try to interpret and bend to those often implicit expectations and traditions.
I went to a talk about outdoor therapy once where a therapist asked, “but how can it be contained when it’s not in a room?” But how can physical walls ever do the work of the containment and holding that needs to happen collaboratively within a relationship?
As a client, I have personally sometimes found working in a room to be oppressive when my feelings are so big, with no movement or landscape to absorb them, and at other times I’ve needed more enclosed spaces or less movement to feel less exposed or more able to connect with and communicate certain thoughts and feelings.
The sudden transition from inside a room to out in the street can also feel like I am suddenly outside dealing with traffic noise and pedestrians while everything that was unpacked in the session is still hanging out. In my scrambling to re-pack everything I can end up just dissociating from it all rather than letting things settle and process. In my personal therapy we walk from a rural setting back into a village, so the transition feels gradual, and manageable for me. So what is it, exactly, about a set of walls that is intrinsically holding or containing?
Perhaps this is very typically autistic of me, but I like to understand why we do things, and I have a deep aversion to the doing of things that don’t make sense.
Another good reason to really interrogate why we do the things we do (and whether we might do them differently) is that it means we are able to talk about it, and own the choices that we make, and help the people we work with feel more empowered in what they are participating in.
A thing to consider is that even when it feels like we’re not choosing to do anything different or unusual in how we work, we are still making a choice — we are choosing to follow a dominant narrative of therapy, or to practise in the way that we’ve been taught, or in a way that feels good or right or ‘normal’ for us. That’s okay, unless we can’t own that it’s a choice, and justify why we do it.
Power imbalances can thrive in ambiguity about as much as autistic folks can often be overwhelmed by it. Autistic people often talk about the anxiety of not knowing what is and isn’t allowed in therapy, of the fear of accidentally stumbling into invisible boundaries or rules, or the worry that can come with really wanting to ask for or challenge something, but not knowing how it will be received.
Often at the start of sessions or in the introductory chat, depending on what comes up, I might tell folks that we don’t have to use any emotional vocabulary if they don’t want to. It can be helpful to repeatedly and explicitly support individuals in realising that they can’t really do therapy wrong. When relevant, I explicitly welcome diversions, non-linear explorations, and distractions. Silence, excited info-dumping, movement, analogies however niche, hypotheticals however unlikely, and any and all questions are similarly all explicitly welcome. Sessions sometimes finish early, and that’s okay. If it feels helpful and wanted, and if I’m feeling able to accommodate it, longer sessions are also possible. When I can’t do something I always try and give a reason why, and own that decision, rather than lean back on things like ‘this is how it’s done’.
I try to do this because I believe that being as clear and open as possible, owning our decisions, and trying not to take any aspects of therapy for granted, are important ways of evening out the power imbalance inherent in therapeutic relationships, and can help to model a more malleable, flexible, and collaborative therapy space that we can both mould together to suit our needs and preferences.
While I believe that this is of course important in therapy and similar helping relationships in general, with all types of people, I believe that this is particularly important when working with neurodivergent people, where the impacts of power imbalances, the Double Empathy Problem, and anxiety about getting a situation wrong, can be particularly pronounced.
While a lot of therapy training will cover therapist self care, they also generally don’t go very deeply into the ways in which our varying, diverse, and idiosyncratic needs as therapists might shape our therapy work. This is needed, I think, especially as increasing numbers of therapists themselves are realising that they are neurodivergent. Not going into this exploration can lead to two unhelpful outcomes — the therapist bends themselves to the norms of therapy, even when it makes them a less capable and effective practitioner, and might not also see that they are expecting the same of their clients, or the therapist shapes their practice around their differences unconsciously, thereby potentially also unconsciously expecting the client to bend to their preferences.
When we do the continuous work of looking at what our own needs, preferences, and differences are, how they impact our practice, and we can talk about it openly, we also model reclaiming and owning our different and divergent ways of being for the people we come into contact with. For example my email policy is that the people I work with can email me as much as they want to or need to, and I will do my best to read and respond — but I will only be able to read and respond to what’s within my capacity, which can vary week on week. Sometimes I will just send an acknowledgement and note that while the email is welcome, I am low on spoons or time so can’t give a detailed response in writing. Other times I might have space to give a more detailed reply. I also have an auto-response that states that I generally attend to non-urgent emails at specific times every few days, rather than as they come in, to help set expectations about response time.
In sessions my monotropic approach to processing sound might mean that if I hear another noise outside, I might momentarily miss what the person has said — I will generally share what happened and why I was distracted. Being clear is about advocacy and openness, and also leaving less space for people to wonder if they did something wrong, or worry if they need to take responsibility for an ambiguity that it’s actually within my power to dispel.
Something that can come up a lot when working with neurodivergent folks, I’ve found, is a fear that we are not allowed to be open about our differences, to imagine new ways of working, or to reclaim old ways of being that we were shamed out of. I believe that we don’t need to be knowingly neurodivergent to model this reclaiming for those we support, because on some level we all feel the pressure to mask or change some parts of ourselves, even if it isn’t to the same extent and detriment as those of us who are, say, autistic or ADHD.
Sometimes this process of reclaiming and reconnecting with our more congruent ways of being can be as simple as talking about our sensory preferences — the preferred texture or shape of one tea mug over another, for example, the preferred angle of a chair (or sitting on the floor). I sometimes share my fascination for pavement plants, how they are both an intense interest and also help ground me in the moment when I’m out and about. Or I might share how I feel about one pebble over another. Back on my therapy placement when I worked in a slightly dilapidated ex-council building, I connected with a number of people through our fascination and feelings towards the weird colour choices and peeling paint patches.
This might all seem really simple — some of it might even sound dangerously like small talk! But I believe that for those of us who have spent so much of our lives being shamed out of having our own choices and preferences, or having them invalidated or seen as wrong, connecting and sharing these small, inconsequential-seeming feelings and impressions with another person, and really being heard, can be the start of reclaiming a lot of important and lost parts of ourselves, and being able to get more in touch with the processes that move inexorably towards growth, change, and greater congruence and self-compassion that I believe are within all of us.
Earlier I talked about how I often tell people that we don’t have to use emotional vocabulary if we don’t want to. Being asked how we feel is something a lot of autistic folks can struggle with in therapy. It can pose a significant barrier for a lot of people who might be told, explicitly or implicitly, that they aren’t engaging or aren’t suited to therapy work. But I believe that the language we are expected to use in therapy is also based around unhelpfully normative expectations, and it is perfectly possible to engage on and communicate complex emotional themes without using any of that.
Talking about sensory preferences and bodily sensations can be a big part of that — because emotions are deeply embodied and, I feel, can sometimes provide more nuanced information on how things are, than just ‘happy’, ‘sad’, ‘depressed’, etc. The quality of my stomach ache or backache can often tell me far more about the type of anxiety, stress, or tension I’m holding in my body, than the words themselves are ever able to categorise.
An extension of this that a lot of people I find really respond to is using analogy or metaphor to describe our felt sense of a thing. There’s a misconception that autistic people don’t understand or like analogies or metaphors, and while there will be some in any population who don’t, in my experience many of us love analogies, but they need to resonate with our felt sense of what we are trying to describe — otherwise what’s the point? What I personally don’t like is metaphors that don’t resonate. I’d probably never sincerely say it’s raining cats and dogs because I’ve never experienced rain that feels to me like cats and dogs are falling from the sky. I expect I’ll change my mind if I ever encounter rain that does that!
There’s a wonderful episode of Pablo, the cartoon about a young autistic boy and the animal friends he draws shown on RTE and BBC, where he describes himself as being ‘scribbly’ — and there’s a big scribble drawn over his body that moves around in a wonderfully evocatively scribbly way. Who says we can’t use metaphors! It makes so much sense to me that Pablo, who processes and explores so much of his world and himself through drawing, would find a name for how he’s feeling in the world of drawing and mark making — and it’s clear throughout the episode what he means by it. He’s feeling scribbly, it’s kind of unpleasant, he wants it to stop, and there’s no better word to describe it. At the end of the episode, he figures out that his jumper is uncomfortable, and causing the scribbly feeling, but it’s clear at least to me that the feeling is as much emotional as it is sensory, and identifying it helped him to process it, ask for help, and find a solution.
I don’t know what this is like to view for non-autistic people, but it also allowed me, as an autistic viewer, to feel intensely empathetically connected with that feeling on a sensory and emotional level. Feeling scribbly makes absolute sense to me.
In work with my clients, and also in my own personal therapy and day to day life, there can be a lot of playfulness with metaphor, analogy, and finding all kinds of different ways to connect with and identify a felt sense. I might say that I feel like I’m in the middle of a tangly wood — and be able to point to a wood on the hillside that looks like how I feel. We might reference relatable gifs or memes in sessions. Folks might build metaphors around their interests or the things they see in the room.
Incidentally when I used the tangly wood analogy, it was in my own therapy. My therapist and I explored it together, playfully, fully inhabiting the world of the analogy and the felt sense of it, as well as exploring it in real life — it was a real wood, after all. As we walked and saw it from different angles, it started feeling more navigable, and somehow that also allowed me to feel less overwhelmed by the internal emotional tangle. Seeing the edges of the real wood helped me start to identify the edges of those feelings, and realise that it wasn’t consuming all aspects of my life.
Often, paradoxically, I think we can all communicate far more effectively about emotions if we don’t try too hard to actually talk about emotions.
As our experiences and feelings emerge and come into awareness, and become louder and start to encompass more aspects of our lives, many neurodivergent people can start to connect more with the ways in which our differences are not acknowledged, and the ways in which neurotypical society might often be unwelcoming, even hostile, to divergent ways of being. I feel that it’s always important here to understand the broader context and ways in which power, privilege, and oppression impact individuals and their experiences.
What might trauma work need to look like if the person is still experiencing repeated traumas as a result of their sensorily inhospitable environment, or due to discrimination and prejudice? How do we conceptualise community when the individual is isolated due to meaningful community being inaccessible? How do we think about resilience or independence when a person has already had to develop exhausting levels of resilience to survive being autistic in a neurotypical world, or when independence is actually often code for ‘not needing more-uncommon forms of support’? As practitioners, or as anyone who supports autistic people, I think it’s really important that we work continually to understand the landscape that being autistic can sit within, in broader society.
It’s never possible to understand what it’s like to be every autistic person — I’d argue it’s never possible to fully know what it’s like to be any other person full stop. But we can do everything we can to understand the context of how society treats autistic people, how neurodivergence is discriminated against, the potential social and economic impacts of being autistic; things like housing and employment instability, medical discrimination or lack of understanding, bullying, poorly understood co-occurring conditions, intersecting minority identities, and so on. We can work to learn about this landscape, and also reflect deeply, perhaps even in our own therapy, on where we ourselves are positioned — are you also neurodivergent? Do you have certain passing privileges, or certain under-recognised difficulties? What about the pieces of internalised ableism that sit in all of us? What might you take for granted about communication, connection, a fulfilling life, executive functioning, sensory experiences? Could there be areas to expand on there in your sensitivity or understanding?
I think of doing therapy sometimes as being like agreeing to go on a journey together with the person coming to therapy. It’s their journey, and my job is to support them by, as much as possible, travelling at their pace, working continually to stay in their frame of reference so I’m not accidentally just walking off in another direction, and also having an awareness of the landscape we’re travelling in and my own physical and emotional limitations, so that I can take responsibility for myself, and also not rely on the person I’m meant to be supporting to point out all the context for me, or teach me about the mountains and rivers that I should be working to be aware of already. One of the things I find really exciting about therapy is that, like most journeys we undertake wholeheartedly and open-heartedly, it can change us, even when we are in the supporting role.
Sometimes I think that therapists and other practitioners are not always prepared for the internal changes that can occur from relating deeply with a person with confusingly different (or disorientingly similar!) experiences to their own. When the practitioner doesn’t have adequate support, or isn’t open to this change, big ruptures can occur that can be deeply harmful to clients who perhaps only just started feeling safe enough to be themselves.
Rounding up, I want to leave you all with some questions to reflect on; invitations to think about how you work, the norms you might be reinforcing, and how you could expand your imaginations and sensitivities to be more welcoming to more diverse ways of being.
- What stories do you tell yourself, or have been told to you, about your work (whatever your work is)? Is this the only way to tell that story?
- What stories do you tell yourself, or have been told to you, about ways of being in the world?
By this I mean things like: ways to have relationships, ways to experience your sensory world, ways to have satisfying social connections, ways to relax, ways to feel fulfilled, ways it’s ‘okay’ to be a person?
Do you think these stories are diverse or expansive enough to be welcoming of many different ways of being?
- What might you need to do when you feel scribbly?
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