Tailoring therapy for neurodivergence

As someone with visible and invisible diversity, who has lived in different countries, and who has diagnoses of different neurodevelopmental conditions, I have experienced the confusion of therapy from childhood to adulthood. I have seen firsthand how alienating therapy can be when it does not consider specific needs and when our differences are seen as 'abnormalities'. As a professional adult, I realise that such struggles are common in the neurodivergent population. Many of us believe it is time for the mental health field to develop further and offer therapies where adjustments go beyond logistics and focus on the therapeutic relationship and tailoring of the therapy approach. 

Therapy is not 'one-size-fits-all', especially for those of us who are neurodivergent. For this article, and in deference to people with lived experience, I will be referring to myself and the community of people with neurodevelopmental conditions like dyspraxia, ADHD, autism, dyslexia, dyscalculia, dysgraphia, Tourette syndrome, etc., as neurodivergent. I will also use neurodiversity as the umbrella term referring to all people with typical and different types of neurodevelopment. 

These concepts have been created collectively by groups of people with lived experience over the decades (Armstrong, 2015; Dekker, 2023; Meyerding, 2014), not by one individual, as also recently confirmed by the hard work of Botha et al. (2024). I encourage readers to model acceptance by using each individual's preference when it comes to language, as I have done throughout this article. I also aim to be inclusive; although I focus on people with neurodevelopmental conditions without intellectual impairment, some of the elements here may be relevant to other populations. 

Challenges neurodivergent people face in therapy

A common experience among neurodivergent individuals is the feeling of not being understood by therapists. One of my Aspie friends has expressed frustrations about using therapy time to 'educate' their therapist about their conditions rather than focusing on their own therapeutic goals. This may be associated with therapist confidence rather than a lack of knowledge, as Cooper et al. (2018) and Dagnan et al. (2015) highlighted. A dyspraxic peer has described how their dyspraxia challenges that impact relationships and work are often dismissed as 'exaggerations' by therapists, thus failing to validate their experiences. 

Such lack of understanding and acceptance negatively impacts access to mental health support in mainstream services for minority populations (Bansal et al., 2022; Camm-Crosbie et al., 2019; Engel-Yeger & Engel, 2023). Aspigurl/Lily, Spectrum (2024) conveys the latter in an ingenious visual way. 

Mental health challenges and neurodivergence

Neurodivergent people experience high rates of mental health challenges and low quality of life (Ayres et al., 2018; Lai et al., 2019; Forde & Smyth, 2022; Lowe et al., 2019). While having a neurodevelopmental condition does not cause mental health challenges or struggles, living in a world that is not designed for us increases vulnerability to adversity such as bullying, marginalisation, and constant exposure to stressors that can lead to more severe mental health challenges (Cuenca et al., 2015; Davies et al., 2023; Gulisano et al., 2020; O'Dea et al., 2021; Ross, 2021; Tsai et al., 2020). 

Unfortunately, inaccessibility to services increases inequalities and may contribute to fewer opportunities for us to improve our quality of life (Stern et al., 2005; Weir et al., 2022). Moreover, our struggles are from birth to death, and support is often more available in childhood, often overlooking that we are an ageing population (Brotman et al., 2021; Janicki et al., 2008; Kirby, 2023; Povey et al., 2011).

In the neurodivergent population, nuanced adjustments may be required to create equitable access for us as neurodivergent clients/service users. In the past, perhaps you heard the word equality, which means providing all the same resources, treatment, and opportunities. However, this notion always made me uncomfortable because we are not the same, and even if systems offer the same opportunity for minority populations such as neurodivergents, if it is inaccessible, then the offer is rendered moot. 

The availability of resources is not sufficient; Howard and Sedgewick (2021) explain a simple and powerful feature of how sometimes essential services are not accessible to people like us. We need equity, which considers the nuances and implementation of adjustments for people with visible and invisible multi-diversity to overcome barriers and prevent putting some at a disadvantage (National Association of Colleges and Employers [NACE], 2023; University of Virginia, 2024).

There are guidelines and examples of adjustments for mental health support. But from a neurodivergent mental health professional perspective, recommendations may be vague and focus on logistics (e.g., Davis III et al., 2014; NICE, CG142, 2012; Russell et al., 2020), which may lead to low engagement (e.g., Flygare et al., 2020). The inclusion of passions or interests to support engagement and well-being has been discussed in research with neurotypical (e.g., Bailey, 2023; Israel et al., 2022; Kakacek, 2017; Takeda et al., 2015) and autistic adults (e.g., Goldfarb et al., 2019; Harrop et al., 2019; Horwood et al., 2021). Special interests/passions have been shown to significantly impact the quality of life in autistic adults (e.g., Deserno et al., 2018; Grove et al., 2018), and perhaps this may extend to the broader neurodivergent population. Still, there is the question of how exactly these are implemented in therapy with fidelity to the model.

Moving toward neuroaffirmative practices

There is a growing recognition that the therapeutic encounter needs to go beyond just adapting materials or formats (Association of Neurodivergent Therapists [ANDT], 2021; Dyspraxia DCD Ireland, 2007) and a need to pay attention to the therapeutic relationship regardless of the approach. Unfortunately, research focuses on one or two neurodevelopmental conditions and one therapy modality, which may not be enough (e.g., Spain & Happé, 2020). Adjusting how therapy is delivered flexibly with fidelity using evidence-based practices has been discussed (e.g., Fisher et al., 2022; Kendall et al., 2007), often recommending the creation of manuals, but these again may be lacking. 

Perhaps what is missing is the co-creation of guidance to provide explicit examples of how different psychological approaches have been successfully implemented and tailored to support the diverse neurodivergent population whilst considering the role of the therapeutic relationship. This should reflect real experiences from the neurodivergent population, highlighting flexible applications whilst keeping the core features of psychological models.

Neuroaffirmative practices highlight the importance of seeing neurological differences as part of the natural human variation rather than disorders to be 'cured' or people that need to be 'changed'. In a neuroaffirmative framework, therapists work collaboratively with neurodivergent clients to identify strengths and build on them while also addressing areas of challenge. In a world increasingly recognising the importance of multi-diversity, the mental health field must also evolve to include and support neurodivergent clients beyond practical adjustments. Therapists can play a vital role in reducing the mental health disparities faced by the neurodivergent population, thus fostering a more inclusive and accepting society (e.g., Horvath & Luborsky, 1993; Norcross, 2011).

Co-produced guidance and next steps

So, therapists need explicit examples of how to make therapy accessible and effective for neurodivergent people. Co-produced research involving neurodivergent communities in creating therapeutic adjustments is essential. 

As a neurodivergent professional and researcher, I am conducting a co-designed project to explore supportive adjustments in therapy for the neurodivergent population, considering the therapeutic relationship. By gathering insights from the neurodivergent community, we can co-develop and improve evidence-based practices to create more inclusive, effective mental health care for the neurodivergent population, thus ensuring equity. 

Find out more about the research project here. By participating, you can help shape the future of mental health support for the neurodivergent community. Together, we can create a more accessible and inclusive therapy.

• Dr Nahory Hernández Mancilla (DHealth-Neurodiversity, CAP, MSc, FMBPsS)

References

Armstrong, T. (2015). The Myth of the Normal Brain: Embracing Neurodiversity. AMA Journal of Ethics, Medicine and Society, 17(4), 348-352. 

Association of Neurodivergent Therapists (ANDT). (2021, July). Association of Neurodivergent Therapist. 

Aspugirl. (2024). Autism: A diamond in a world of squares. Epistemic Injustice.

Ayres, M., Parr, J. R., Rodgers, J., Mason, D., Avery, L., & Flynn, D. (2018). A systematic review of quality of life of adults on the autism spectrum. Autism : the international journal of research and practice, 22(7), 774–783. 

Bailey, C. (2023). 'Neurodivergent literacies': exploring autistic adults' 'ruling passions' and embracing neurodiversity through classroom literacies. Literacy, 57(2), 120–131. 

Bansal, N., Karlsen, S., Sashidharan, S. P., Cohen, R., Chew-Graham, C. A., & Malpass, A. (2022). Understanding ethnic inequalities in mental healthcare in the UK: A meta-ethnography. PLoS medicine, 19(12), e1004139. 

Botha, M., Chapman, R., Giwa Onaiwu, M., Kapp, S. K., Stannard Ashley, A., & Walker, N. (2024). The neurodiversity concept was developed collectively: An overdue correction on the origins of neurodiversity theory. Autism, 28(6), 1591–1594. 

Brotman, S., Sussman, T., Pacheco, L., Dickson, D., Lach, L., Raymond, É., Deshaies, M. H., Freitas, Z., & Milot, É. (2021). The Crisis Facing Older People Living with Neurodiversity and Their Aging Family Carers: A Social Work Perspective. Journal of gerontological social work, 64(5), 547–556.

Camm-Crosbie, L., Bradley, L., Shaw, R., Baron-Cohen, S., & Cassidy, S. (2019). 'People like me don't get support': Autistic adults' experiences of support and treatment for mental health difficulties, self-injury and suicidality. Autism: the international journal of research and practice, 23(6), 1431–1441. 

Cooper, K., Loades, M. E., & Russell, A. J. (2018). Adapting Psychological Therapies for Autism - Therapist Experience, Skills and Confidence. Research in autism spectrum disorders, 45, 43–50. 

Cuenca, J., Glazebrook,C., Kendall, T., et al. (2015). Perceptions of treatment for tics among young people with Tourette syndrome and their parents: a mixed methods study. BMC Psychiatry, 15(46), 1–12.

Dagnan, D., Masson, J., Cavagin, A., Thwaites, R., & Hatton, C. (2015). The Development of a Measure of Confidence in Delivering Therapy to People with Intellectual Disabilities. Clinical psychology & psychotherapy, 22(5), 392–398. 

Davies, C., Moosa, M., McKenna, K., Mittal, J., Memis, I., Mittal, R., & Eshraghi, A. A. (2023). Quality of Life, Neurosensory Disorders and Co-Occurring Medical Conditions in Individuals on the Spectrum, with a Special Focus on Females Diagnosed with Autism: A Systematic Review. Journal of Clinical Medicine, 12(3), 927. 

Davis III, T., White, S., & Ollendick, T. (2014). Handbook of Autism and Anxiety (1st ed.). Autism and Child Psychopathology Series. Cham: Springer International Publishing: Imprint: Springer.

Dekker, M. (2023, July 13). A correction on the origin of the term 'neurodiversity'. Independent living on the autistic spectrum: Where those who are different find that they're not alone. Martijn 'McDutchie' Dekker. 

Deserno, M. K., Borsboom, D., Begeer, S., & Geurts, H. M. (2018). Relating ASD symptoms to well-being: moving across different construct levels. Psychological medicine, 48(7), 1179–1189. 

Dyspraxia DCD Ireland 2007-2023. (2023). Dyspraxia DCD, Counselling Service. 

Engel-Yeger, B. & Engel, A. (2023). Emotional distress and quality of life among adults with developmental coordination disorder during COVID-19. The British journal of occupational therapy, 86(2), 130–138. 

Fisher, N., Patel, H., van Diest, C., & Spain, D. (2022). Using eye movement desensitisation and reprocessing (EMDR) with autistic individuals: A qualitative interview study with EMDR therapists. Psychology and Psychotherapy: Theory, Research and Practice, 95(4), 1071–1089.

Forde, J. J., & Smyth, S. (2022). Avoidance Behavior in Adults with Developmental Coordination Disorder is Related to Quality of Life. Journal of Developmental and Physical Disabilities, 34(4), 571-589. 

Flygare, O., Andersson, E., Ringberg, H., Hellstadius, A-C., Edbacken, J., Enander, J., Dahl, M., Aspvall, K., Windh, I., Russell, A., Mataix-Cols, D., & Ruck, C. (2020). Adapted cognitive behavior therapy for obsessive compulsive disorder with co-occurring autism spectrum disorder: A clinical effectiveness study. Autism, 24(1), 190-199. 

Goldfarb, Y., Gal, E., & Golan, O. (2019). A Conflict of Interests: A Motivational Perspective on Special Interests and Employment Success of Adults with ASD. Journal of Autism and Developmental Disorders, 49(9), 3915–3923.

Grove, R., Hoekstra, R., Wierda, M., & Begeer, S. (2018). Special interests and subjective wellbeing in autistic adults. Autism Research, 11(5), 766-775. 

Gulisano, M., Barone, R., Alaimo, S., et al. (2020). Disentangling Restrictive and Repetitive Behaviors and Social Impairments in Children and Adolescents with Gilles de la Tourette Syndrome and Autism Spectrum Disorder. Brain Sciences, 10(5), 308. 

Harrop, C., Amsbary, J., Towner-Wright, S., Reichow, B., & Boyd, B. A. (2019). That's what I like: The use of circumscribed interests within interventions for individuals with autism spectrum disorder. A systematic review. Research in Autism Spectrum Disorders, 57, 63–86. 

Horwood, J., Cooper, K., Harvey, H., Davies, L., & Russell, A. (2021). The experience of autistic adults accessing adapted cognitive behaviour therapy: ADEPT (Autism Depression Trial) qualitative evaluation. Research in Autism Spectrum Disorders, 86, [101802]. 

Howard, P. L., & Sedgewick, F. (2021). 'Anything but the phone!': Communication mode preferences in the autism community. Autism, 25(8), 2265–2278. 

Israel, S. M., Adams-Price, C. E., Bolstad, C. J., & Nadorff, D. K. (2022). Age and recognition for one's creative hobby are associated with fewer depressive symptoms in middle-aged and older adults. Psychology of Aesthetics, Creativity, and the Arts, 16(4), 610–617. 

Janicki, M., Henderson, C., & Rubin, L. (2008). Neurodevelopmental conditions and aging: Report on the Atlanta charrette study group on neurodevelopmental conditions and aging. Disability and Health, 1(2), 116–124. 

Kakacek, S. L., (2017). Equine-assisted psychotherapy: Applying strengths-based solutions in an arena for change. In J. K. Edwards, A. Young & H. J. Nikels (Eds.), Handbook of strengths-based clinical practices: Finding common factors (1st ed., pp. 192–206). Routledge-Taylor & Francis Group. 

Kendall, P. C., & Beidas, R. S. (2007). Smoothing the trail for dissemination of evidence-based practices for youth: Flexibility within fidelity. Professional Psychology: Research and Practice, 38(1), 13–20. 

Kirby, A. (2023, August 23). Neurodiversity and ageing - What do we know? Elder. 

Lai, M.-C., Kassee, C., Besney, R., Bonato, S., Hull, L., Mandy, W., Szatmari, P., & Ameis, S. H. (2019). Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis. The Lancet Psychiatry, 6(10), 819–829. 

Lowe, T., Capriotti, M., & McBurnett, K. (2019). Long‐Term Follow‐up of Patients with Tourette's Syndrome. Movement Disorders Clinical Practice, 6(1), 40-45. 

Meyerding, J. (2014). Thoughts on Finding Myself Differently Brained. Autonomy, The Critical Journal Of Interdisciplinary Autism Studies, 1(2), 1–12. 

National Association of Colleges and Employers (NACE). (2023). EQUITY. NACE Center for Career Development and Talent Acquisition. 

National Institute for Health and Care Excellence (NICE). (2012). Autism spectrum disorder in adults: diagnosis and management: Clinical guideline [CG142]. United Kingdom: NICE. 

Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. Oxford University Press

O'Dea, Á., Stanley, M., Coote, S., & Robinson, K. (2021). Children and young people's experiences of living with developmental coordination disorder/dyspraxia: A systematic review and meta-ethnography of qualitative research. PloS one, 16(3), e0245738.

Povey, C., Mills, R., & Gomez de la Cuesta, G. (2011). Autism and ageing: issues for the future. National Autistic Society (NAS).  

Ross, H. (2021). 'I'm Dyslexic but What Does That Even Mean?': Young People's Experiences of Dyslexia Support Interventions in Mainstream Classrooms. Scandinavian Journal of Disability Research: SJDR, 23(1), 284–294. 

Russell, A., Gaunt, D., Cooper, K., et al. (2020). The feasibility of low intensity psychological therapy for co-occurring depression in adult Autism: The ADEPT study - a pilot randomised controlled trial. Autism, 24(6), 1360-1372. 

Spain, D., & Happé, F. (2020). How to Optimise Cognitive Behaviour Therapy (CBT) for People with Autism Spectrum Disorders (ASD): A Delphi Study. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 38,184–208. 

Stern, J. S., Burza, S., & Robertson, M. M. (2005). Gilles de la Tourette's syndrome and its impact in the UK. Postgraduate medical journal, 81(951), 12–19. 

Takeda, F., Noguchi, H., Monma, T., & Tamiya, N. (2015). How Possibly Do Leisure and Social Activities Impact Mental Health of Middle-Aged Adults in Japan?: An Evidence from a National Longitudinal Survey. PloS one, 10(10), e0139777.

Tsai, C.-H., Chen, K.-L., Li, H.-J., Chen, K.-H., Hsu, C.-W., Lu, C.-H., Hsieh, K.-Y., & Huang, C.-Y., (2020). The symptoms of autism including social communication deficits and repetitive and restricted behaviors are associated with different emotional and behavioral problems. Scientific reports, 10(1), 20509–20509. 

University of Virginia. (2024). What are Diversity, Equity, and Inclusion (DEI)? 

Weir, E., Allison, C., & Baron-Cohen, S. (2022). Autistic adults have poorer quality healthcare and worse health based on self-report data. Molecular autism, 13(1), 23.