Awareness, Acceptance, and Beyond: Neurodiversity-Affirming Therapy with Autistic Clients
Note: This blog was initially written for a Sacramento-based therapist directory in April 2022 for Autism Acceptance Month. It has been re-posted here with minor edits and updates.
The month of April has long been designated “Autism Awareness Month”. The Autistic community, however, predominantly prefers that April be named “Autism Acceptance Month”.
What’s the difference? Months dedicated to raising awareness tend to focus on issues that need curative or preventative efforts. Breast Cancer Awareness Month and Domestic Violence Awareness Month are examples. Autism is not an issue to be cured or prevented. Autism is a neurotype, “simply part of the natural spectrum of human biodiversity, like variants in ethnicity or sexual orientation” (https://neuroqueer.com/what-is-autism/).
Autism Awareness and the Pathology Paradigm
Autism Awareness Month is a reflection of the Pathology Paradigm. The Pathology Paradigm, which dominates fields including psychology and education, holds that there is one “right” or “normal” kind of neurocognitive functioning. Anything that diverges from the norm is considered a deficit or disorder.
The Pathology Paradigm is reflected in the language used to talk about autism. For example, while the Autistic community largely prefers identity-first language (described below), person-first language is most frequently used among non-autistics, especially professionals.
Identity-first language: “They are autistic;” “His best friend is an autistic woman.”
Person-first language: “They are a person with autism;” “His best friend is a woman with autism.”
Person-first language reinforces the idea that autism is a pathology that a person would never proudly identify with. Identity-first language acknowledges that a person’s identity is central to their lived experience, and that it can be a source of community and pride. This linguistic distinction may seem insignificant or nit-picky, but it reflects and reveals larger societal attitudes about autism. If you are ever unsure of how to refer to someone, it is best to listen to the way that they refer to themselves.
Autism Acceptance & the Neurodiversity Paradigm
The move from Autism Awareness to Autism Acceptance is a necessary shift for the health and wellbeing of autistic people of all ages.
Autistic children are still subjected to therapies like Applied Behavior Analysis (ABA) which has historically aimed to reduce Autistic traits so that autistic children can become less distinguishable from their non-autistic peers. Autistic traits that have been targeted with ABA include self-stimulatory behaviors or “stimming” (hand-flapping, spinning, swaying, rocking, clapping, humming, etc.), communication differences, discomfort with eye contact, and sensitivities to distressing sensory stimuli.
Many Autistic teens and adults report masking or camouflaging in order to be accepted by others. Masking and camouflaging involve repressing autistic traits in order to be perceived as neurotypical. This can lead to increased stress, depression, anxiety, self-esteem issues, identity confusion, chronic health issues, and burnout.
The neurodiversity paradigm affirms that individuals of all neurotypes have traits and needs which are deserving of consideration and respect. It values biodiversity over adherence to social norms. Autistic individuals should not be expected to conform to society’s neurotypical mold. Unfortunately, the field of psychotherapy has aided in efforts to make Autistic clients appear more neurotypical by referring Autistic clients to social skills groups and ABA services, creating treatment goals that are based on neurotypical standards, or using therapeutic approaches that are not a match for Autistic needs.
Neurodiversity-Affirming Therapy
A neurodiversity-affirming approach to psychotherapy can support Autistic clients to build a positive Autistic identity and better understand their needs.
A neurodiversity-affirming approach is strength-based rather than deficit-based. Well-meaning therapists who would consider themselves strength-based practitioners may unknowingly engage in a deficit-based approach with Autistic clients. A neurodiversity-affirming approach acknowledges that Autistic clients may have needs that are different from non-autistic (“allistic”) clients. Rather than viewing these needs as deficits, Autistic clients’ needs are held with acceptance, validation, and a focus on increasing support where needed.
A neurodiversity-affirming approach is a trauma-informed approach. Researcher and neurodiversity advocate, Janae Elisabeth looked at the DSM-5 Autism Spectrum Disorder criteria through a trauma lens, identifying ways in which the criteria reflect distress, trauma, or the pathologization of Autistic norms. For example, the DSM-5 criteria for Autism Spectrum Disorder includes persistent deficits in social communication and social interaction, such as deficits in social-emotional reciprocity. Elisabeth writes, “a stressed or traumatized autistic person will not feel safe to hold conversation, share interests, or initiate social interactions because of the trauma associated with past attempts.” Additionally, explains Elisabeth, “the expectation of back and forth conversation is uniquely neurotypical. Autistic people do not need to speak to share social information, we have different cultural conversation patterns, and we often prefer to let others initiate socialization so that we can be sure they are participating willingly”.
It is critical that therapists who work with autistic clients learn about autistic experience and autistic culture with respect and humility. Therapists need to identify and reflect on biases in order to provide competent and affirming care. Unexamined biases can lead a therapist to pathologize unproblematic autistic traits.
The mainstream myth that autistic people lack empathy is an example of a neuronormative bias that often enters the therapy room. A theory called the Double Empathy Problem reveals that autistic people do not necessarily lack empathy, but rather, autistic and non-autistic people have trouble understanding one another. In other words, there is a two-way difficulty occurring. However, when autism is framed as a pathology that causes deficits in empathy, allistic individuals are never called to confront their own misunderstandings of autistic communication styles, needs, and experiences. It is important to be wary of this dynamic in the therapy room where allistic therapists hold professional power over autistic clients. Therapists have the power to diagnose and pathologize without reflecting on whether or not they are biased in the matter. The Double Empathy Problem suggests that autistic individuals understand and feel more comfortable with other autistics. Autistic clients may be better matched to work with Autistic therapists.
Finally, a neurodiversity-affirming approach to therapy asserts that autistic individuals have a right to autonomy and self-determination. The Autistic Self Advocacy Network (ASAN), a disability rights organization run by and for the autistic community, holds the motto: “Nothing About Us Without Us.” ASAN explains, “autistic people need to be involved whenever autism is discussed. When non-autistic people make decisions about autism without Autistic input, those decisions are usually bad. This makes it harder for us to get by in the world. Decisions about autism need to be made with autistic people.”
Therapists who work with the autistic community can learn about autism directly from autistics. This can include actively listening to autistic clients while checking biases, seeking out trainings led by autistic professionals, reading blogs or books by autistic people, and consulting with autistic therapists.
Note: This blog was initially written for a Sacramento-based therapist directory in April 2022 for Autism Acceptance Month. It has been re-posted here with minor edits and updates.
Lou is a queer, autistic, multiply neurodivergent therapist in California.
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