Why Therapy Fails Autistic Adults: Masking, Trauma, and Neurodiversity-Affirming Care

The Deeper Reasons Why Therapy Fails Autistic and Neurodivergent Clients

By Dan Spring, RCC, CCC

There is a small body of online articles with opinions on why therapy fails autistic or neurodivergent adults. Many of these articles point to the complications clients face when therapy encourages conformance and ignores neurodivergent needs. These narratives correctly explain that in hopes of improving their experiences, many neurodivergent adults seek counselling therapy, but leave feeling misunderstood and pressured to perform in uncomfortable ways. 

To summarize these articles, when a neurodivergent person reaches out to a therapist, they are often told that they need to continue putting effort into succeeding at conforming to neurotypical social expectations, even when this very activity has led to profound trauma and burnout. In many forms of therapy, this includes demands to improve in performing neurotypical styles of eye contact, emotional intelligence, verbal fluency, reciprocal conversation, executive functioning, or emotional regulation. Consider this list for a moment and what the words imply. Therapeutic language encourages therapists to view neurodivergent people as emotionally unintelligent, non-reciprocal, and emotionally dysregulated. 

The reason the blame is put on neurodivergent people when they fail to conform is that the field of psychology, as long as it has been around, has placed the burden of social failure on the client. This is referred to as a pathologizing approach. Meanwhile, there are certain things that neurodivergent people can’t change about themselves. So their “failures” continue without a therapeutic solution. A more compassionate, non-pathologizing approach takes the blame off of the neurodivergent person and considers what neurodivergent people can do to change their interactions with social and physical environments, so that they can live more comfortable and healthy lives. 

While this is an important entry point, there are further considerations that can also cause therapeutic failure.

1. Not all therapy addresses a lifetime of social trauma.

Many neurodivergent people struggle with trying to fit in their entire lives. Some of us are not diagnosed until we are adults, stirring questions around how we should understand our personal histories and what we can change to make our lives better. This re-examination should be supported in a therapeutic setting, but too frequently, it’s overlooked. For autistic and neurodivergent adults who were diagnosed early, memories of therapy can be so painful that we might avoid it altogether. Many therapeutic approaches focus on the present and fail to consider the effects of a lifetime of perceived social failures, leading to complex trauma.

For example, when neurodivergent people mask, it can be like walking a tight rope. It’s stressful to do, and the results can be traumatic when we fail: the loss of jobs, family connections, and friendship groups. We might be stigmatized for being “weird,” “socially awkward,” or even completely “asocial,” as the DSM-5-TR would have us believe. The trauma of loss and stigmatization can compound over time, causing long-term burnout and depression.

2. There are many types of neurodivergence

While there are many common experiences among neurodivergent people that can be addressed in therapy, there can also be some fairly large differences. A specific autistic person may have both different and similar concerns to a specific person living with bipolar. These are not cosmetic variations, and they frequently present in a way that is not coherent with diagnostic manuals. Expertise in understanding and supporting these differences is crucial to achieving productive therapeutic outcomes. 

For example, autistic people are not the only ones who experience sensory sensitivities. People with bipolar can also experience significant challenges when exposed to too much sensory information. Neurodivergent characteristics aren’t neatly divided up by diagnosis. 

Some people experience multiple neurodivergence, which means they may identify with having more than one type of neurodivergence (ie ADHD and autism is called “auDHD”), and may experience a wide range of seemingly paradoxical neurodivergent characteristics that interact or present differently in different contexts. 

‍

3. Not all neurodiversity-affirming therapists understand neurodivergent lived experience

Many therapists call themselves “neurodiversity affirming ”after minimal training, or after promising not to engage in types of therapy considered harmful to neurodivergent people. As a result, many neurodivergent clients haven’t experienced therapy with a clinician who brings either lived neurodivergent experience or a significant understanding of it into the therapeutic relationship. 

Without significant knowledge of neurodiversity, it is problematic for a therapist to work with neurodivergent clients. They are more likely to fall back on a pathologizing approach. This means they are more likely to encourage conformance no matter what type of therapy they are using. Even post-modern approaches like narrative therapy can be used to encourage conformance.

4. Even neurodivergent therapists can struggle with internalized ableism

Even when therapists themselves are neurodivergent, they may experience internalized ableism that makes it challenging for them to connecting a therapeutically supportive way with their neurodivergent clients. This is called counter-transference.

For example, if a neurodivergent therapist has experienced trauma and abuse connected with family, work, or friendship dynamics that discourage self-reflection around their own neurodivergent characteristics, they may bring these dynamics into therapy, discouraging the same kind of self-reflection in their clients. In effect, counter-transference can direct therapy away from the kinds of rich therapeutic explorations that neurodivergent people really need.

5. Challenges with unmasking may make it seem that a client doesn’t struggle with masking

Many neurodivergent clients may come to therapy with challenges around unmasking. This can create a kind of therapeutic invisibility. When neurodivergent clients appear to have no challenges with conformance, therapists unfamiliar with unmasking could read this as a sign of emotional health. Yet beneath that presentation, clients may experience a deep disconnection from authentic needs and identity. 

In this way, the very adaptations that help neurodivergent people survive neurotypical environments can become the same adaptations that prevent therapists from understanding them. A therapist who mistakes survival strategies for wellness is likely to recommend even more conformance. In the end, clients may expend more social effort precisely when they need to reflection emotional performance, overwhelming environments, or the effects of adaptation to environments that are causing them harm.

A final word

For therapy to become genuinely effective for neurodivergent adults, therapist education will need to change. Choosing a supportive modality is not enough. A non-pathologizing approach is a good starting place, but expertise is also needed. A deep awareness of the lived experience of neurodiversity is crucial to positive therapeutic outcomes.

‍

About the author

As a father, Dan worked with his son, who is neurodivergent, since he was a child over twenty years ago. That experience inspired him to become an inclusive education teacher, and he spent over ten years working with autistic and neurodivergent children. After that, he became a counsellor and founded Neurodiversity Aware Therapy^TM, a modality specifically designed to support autistic and neurodivergent clients. Recently ,he also became a candidate for a doctorate in the social sciences, and is doing research in the fields of autism and neurodiversity. He is also a diagnosed autistic person. 

To book a session, refer a client, or learn more about Neurodiveristy Aware Therapy^TM please visit Dan’s website at www.neurodiversityawarecounselling.com

‍