Neurodivergence and therapy: what a therapist needs to do differently

“Is it all right if I look out of the window while we talk? When I look at you, I stop hearing what you’re saying.”

It seems like a small sentence. Yet it carries a whole story: years of hearing “look at me when I’m talking to you”, years of performing eye contact instead of listening, and the caution with which someone now asks whether, in a therapy room, they may do the thing that actually helps them. When someone asks a question like this at all, it is a good sign. It means they already know something about themselves. And the therapist’s answer will tell them whether they have come to a place where that knowledge will be taken seriously.

Neurodivergence has been talked about a great deal in recent years, sometimes precisely, sometimes as a fashionable word. In this piece I am less interested in the word itself than in a practical question: what has to change in therapy when the brain of the person sitting opposite works differently from what the authors of most therapy manuals had in mind? I will write about what the professional guidance recommends, what is worth asking a therapist before you start, and where this approach falls short.

What the word neurodivergence means

The term neurodiversity took hold in the late 1990s. It is often linked with the Australian sociologist Judy Singer, who wrote about autism as one form of human difference rather than only as a deficit. From this grew the word neurodivergence: an umbrella term for people whose brains process information, attention, sensory input or social signals noticeably differently from the majority. It most often refers to ADHD and autism, sometimes also to dyslexia, dyspraxia and other differences.

It is important to know what this word is not. It is not a diagnosis, and nobody can give it on the basis of a hunch. In adults, ADHD and autism are diagnosed by a psychiatrist or a clinical psychologist following an established professional procedure. I wrote about who may do what in Who may diagnose, who may prescribe, and who leads the process, and about the route to an assessment in Adult ADHD assessment in Slovenia: where to turn and what to expect. A psychotherapist does not diagnose. What she can do is notice, together with you, when it might make sense to seek an assessment, and support you along the way.

How many people does this concern? A 2021 review by Song and colleagues, which pooled data from many countries, estimates that around 2.6 per cent of adults have ADHD that goes back to childhood, and almost 7 per cent of adults have symptoms of ADHD. For autism, a community study in England (Brugha et al., 2011) found roughly one adult in a hundred, most of them undiagnosed. This means something simple: every therapist who works with adults also works with neurodivergent people. The only question is whether they know it.

Where ordinary therapy gets stuck

Most talking therapies were developed with someone in mind who is at ease with face-to-face conversation, who can put their feelings into words without much effort, who can stay with one topic for fifty minutes and who understands the unspoken rules of the room. For many people that holds true. For neurodivergent people, though, these very taken-for-granted things can become obstacles that have nothing to do with the content of therapy.

• Open, abstract questions. “How do you feel about that?” can be a perfectly clear question for one person and a blank page for another. For many autistic people, recognising and naming their own emotions is slower or takes a different route: through the body, through thoughts, through events.
• Eye contact and reading faces. A therapist who reads looking away as avoidance may misunderstand someone for whom looking away is the only way to listen.
• Sensory load. A buzzing light, a ticking clock, the smell of air freshener, a hard chair. Unnoticeable to one person, they eat up half of another’s attention.
• Unspoken rules. When the session ends, whether I am allowed to interrupt, whether it is a problem if I forget what we talked about last time.
• The expectation that everything will “happen in your head”. With ADHD, executive functions (planning, working memory, getting started) are often precisely what is hard. A homework task that is not written down will most likely vanish. Not out of lack of interest.

None of these things is big. Together, though, they can create an experience in which a person leaves a session tired, feeling they were a “bad client”, and thinking that therapy simply isn’t for them. When in fact only the form was unsuited to them.

Double empathy: a misunderstanding has two ends

In 2012 the British researcher Damian Milton, who is autistic himself, published a short paper that strongly influenced thinking about autism. He named the double empathy problem. For a long time it was assumed that autistic people lack the ability to understand others. Milton pointed out that the misunderstanding is mutual: non-autistic people also read autistic people poorly, only this is rarely counted as a deficit.

Later research began to test this idea. In 2020, for example, Catherine Crompton’s group showed that autistic people pass information to one another just as effectively as non-autistic people do among themselves, and that difficulties appear mainly in mixed pairs. Communication, in other words, does not get stuck “inside one person”, but between two ways of being.

For therapy this matters enormously. If a therapist automatically attributes a misunderstanding to the client, they will repeat exactly the experience the person may have had all their life: that they are always the one who doesn’t understand properly. If, on the other hand, the therapist accepts that the misunderstanding is shared, part of their task becomes learning the language of the person in front of them. This is the relational view in its most practical form: the relationship is not something that happens to the client, but something both people create.

What the professional guidance recommends

Research on how to adapt psychotherapy for neurodivergent adults is still young, so it is fair to say there are no firm recipes. There are, however, guidelines that summarise what is known so far. In its guideline on autism in adults (CG142), the UK’s National Institute for Health and Care Excellence (NICE) recommends adaptations to psychological help for co-occurring difficulties such as anxiety or depression, and they are surprisingly concrete:

• a more concrete and structured approach, with more written and visual information;
• rules and expectations stated clearly, instead of the person having to guess them;
• fewer metaphors, less ambiguity and fewer hypothetical questions;
• regular breaks;
• bringing in the person’s special interests where this makes sense;
• the option of a partner, family member or other supporter taking part, if the person wishes.

The NICE guideline on ADHD (NG87) also mentions structured psychological support for adults, focused on how ADHD affects everyday life, as an option for those who decide against medication or for whom it does not help enough. I won’t go into medication in detail here: decisions about it always rest with a doctor, and psychotherapy neither replaces it nor competes with it.

Something follows from these guidelines that matters to me: adaptations are not a concession or a “lighter version” of therapy. They are the condition for therapy to work at all. Just as a ramp is not a favour, but an entrance.

There is one more side that relational family therapy, in which I am training, always brings to the foreground: people do not live alone. When someone learns as an adult that they have ADHD or are autistic, their relationships often rearrange themselves too: with a partner, with parents, with children. Old stories (“he just doesn’t try”, “she was always odd”) take on a different meaning. So sometimes it makes sense for someone close to join therapy for a few sessions. I described how this works in How joint sessions work: who comes, who speaks and what the therapist does.

Masking doesn’t stop at the door of the therapy room

Many neurodivergent people learned early on how to appear “normal”. In autism research this is called camouflaging or masking: copying facial expressions, preparing sentences in advance, forcing eye contact, hiding the movements that soothe you. In 2017 Laura Hull and colleagues asked autistic adults what this is like for them, and the accounts were similar: masking works, but it costs. Afterwards comes exhaustion, a sense that nobody really knows you, sometimes even losing touch with who you actually are. I wrote more about this in Autism in women and the masking that wears you out.

Why does this matter for therapy? Because masking doesn’t switch itself off when you walk into a therapy room. Quite the opposite: therapy is a new situation with an unfamiliar person, where you want to make a good impression. A neurodivergent person can be a very “good client”: punctual, friendly, answering the questions, nodding at the right moments, and all the while spending energy on being exactly that. A therapist who doesn’t know this may see progress where there is none, or miss how hard things really are.

So one sign of good work is that the therapist slowly creates a space where the mask isn’t needed. Where you may look out of the window, rock on your chair, say “I don’t know what I feel” or “I don’t understand that question”, and none of it will be taken as resistance.

The goal is not to become “more normal”

One of the most sensitive points is the question of what the goal actually is. Many neurodivergent adults received plenty of “help” in childhood and at school whose main purpose was to make them less noticeable, less disruptive, more like everyone else. If therapy continues in the same direction, it can deepen exactly what hurts most: the feeling that something is fundamentally wrong with you. That a diagnosis describes a pattern, not you as a person, is what I wrote about in A diagnosis is a map, not a name for you.

A useful distinction is a simple one: what causes you suffering, and what mainly bothers other people? If rocking helps you gather yourself, there is no reason to get rid of it. But if impulsive decisions are costing you money, or your relationships keep falling apart in the same way, that may be something you genuinely want to change: for your own sake, not to please someone else. Good therapy doesn’t decide for you what belongs in which group. It helps you tell them apart yourself.

Regulation plays a big part here as well. Neurodivergent people often live closer to the edge of their window of tolerance, because everyday life (noise, unpredictability, demands to switch quickly between tasks) puts more strain on them. So part of therapy can be very practical: getting to know what pushes you over the edge and what brings you back.

What is worth asking a therapist

You don’t have to wait for a therapist to work out what you need. At the first session, or even before, in a message, you can ask a few questions. The answers will tell you a lot: not so much through their content as through how the therapist responds.

• Do you have experience with neurodivergent adults, and of what kind? (An honest “less than I would like, but I am learning and working under supervision” is worth more than vague assurances.)
• How do you understand ADHD or autism: as a disorder to be fixed, or as a different way of functioning, with its own difficulties and its own strengths?
• Can we adjust the light, the seat or where I sit in the room?
• Could I get a short written note of what we agreed after the session?
• What happens if I forget an appointment or arrive late?
• Is it all right if I sometimes say I don’t understand a question, or ask you to put it differently?

What might a conversation like this sound like? Something like this (a composite, not a real person):

“Before we start… when someone asks me how I feel, my head goes completely blank. Not because I don’t want to answer.”
“Thank you for telling me. Would it be easier if I asked what you noticed in your body in that moment? Or what you did next?”
“Yes. The body works. Like, that I clenched my jaw.”
“Then let’s start there. We can get to a word for the feeling later, or not at all. The body is a perfectly good way in.”

Nothing special happens here. And that is exactly the point: a small change in a question, accepted by the therapist without hesitation, tells a person that they don’t have to adapt in order to be heard.

Exercise: your map of conditions

Before your first session, or if you are already in therapy but feel that something keeps catching, you can prepare a short note about the conditions in which you think and talk best. You don’t have to show it to anyone. But often the act of writing it clarifies things that are hard to say in the moment.

1. Recall two conversations: one after which you felt heard, and one after which you were exhausted or confused. Write down where they took place and who they were with.
2. Compare the setting. What were the light, the noise, the seating like? Did you sit opposite each other or side by side? Were you walking? Note the differences, including the ones that seem unimportant.
3. Compare the way of talking. Were the questions concrete or open? Did you have time to answer? Was anyone expecting eye contact?
4. Draw three sentences out of this in the form “It’s easier for me when…”. For example: “It’s easier for me when I can turn something over in my hands.”
5. Choose one sentence you will say out loud: to a therapist, a partner or someone else you talk to often. Notice how they respond.

If, while doing the exercise, you realise you don’t know what helps you, that is information too. It may mean you have been adapting for so long that your own needs have not yet had a chance to show themselves. That can be one of the first questions to bring to therapy.

One more thing, briefly: the note is not a test you have to fill in “correctly”. Conditions can change: when you are tired, in a different season, in a different stage of life. So it is worth coming back to it from time to time and adding to it.

Where this approach falls short

Everything I have written also has limits, and they need to be named just as clearly.

First, not every difficulty is a consequence of neurodivergence. When someone receives a diagnosis, or recognises themselves in a description of ADHD or autism, they may start looking at everything through that lens, including distress that has another source: a loss, trauma, a relationship that isn’t working, or depression. Neurodivergence can explain a lot, but not everything. A good therapist will stay curious about other explanations too.

Second, a “neurodivergent-friendly” label guarantees nothing. The phrase has become popular and is sometimes used more as a badge than as a description of the work. What counts more than any label is how a therapist answers your questions and whether adjustments are genuinely possible.

Third, adjustments are not the same for everyone. Some autistic people love a precise structure; others experience it as pressure. Some people with ADHD need breaks; others would rather walk while they talk. The list from the guidelines is a starting point, not a rule.

Fourth, therapy does not replace medical care. Diagnosis, medication and treatment of co-occurring difficulties such as severe depression, eating disorders or addiction belong with a doctor, psychiatrist or clinical psychologist. I described when it is wise to see a psychiatrist first in When you need a psychiatrist first. If thoughts appear that it would be better if you weren’t here, don’t wait for the next session: in Slovenia, call the crisis line Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am), the Samaritans helpline in Slovenia on 116 123 (24 hours a day) or, in an emergency, 112.

And finally: even a therapist who tries hard will sometimes miss. They will ask a question that is too hard, or fail to notice that the room is too loud. What matters is not that there are no mistakes, but that a mistake can be named, and heard. If that isn’t possible in a particular relationship, it is entirely legitimate to look for another therapist.

When therapy becomes a place where you don’t have to translate

Many neurodivergent adults describe everyday life as constant translation: of their thoughts into a language others understand, of their reactions into something socially acceptable, of their pace into the pace of the people around them. This translating is tiring, even when nobody sees it.

Therapy can, though it doesn’t have to, become one of the few places where there is less translating. Where the therapist tries to learn your language, not just you theirs. That doesn’t mean there is no work in therapy, or that there won’t be hard moments. It does mean that the effort you put in goes into what you came for, and not into looking as though you can cope.

If you are only at the beginning and have no idea where to start, that is enough too. I wrote about this in “I don’t know where to start”: more than enough for a first session.

What to remember

• Neurodivergence is not a diagnosis; in adults, ADHD and autism are diagnosed by a psychiatrist or clinical psychologist.
• A misunderstanding between a neurodivergent and a neurotypical person has two ends, in the therapy room too.
• Guidelines recommend concreteness, structure, clear rules, breaks and written information. This is not easier therapy, but the condition for therapy to work.
• You may ask a therapist how they understand neurodivergence and what adjustments are possible. Their response tells you a lot.
• The goal is not for you to become more “normal”, but for life to get easier, and for you to decide for yourself what you want to change.