Neuro-affirming practice: what counsellors and psychotherapists need to know when working with autistic clients and those with attention differences

With thanks to our Neurodiversity Ambassador, Dr Claire Thompson, for this article.

Why this matters now

More people than ever are seeking therapy as autistic people, people with attention differences, or both. Some arrive with a formal diagnosis, whilst others are exploring what these terms might mean for them. Many have spent years being misunderstood, excluded or told that the way they think, feel and communicate is wrong.

Autistic people and people with attention differences experience significantly higher rates of anxiety, depression, trauma and overwhelm than the general population. These difficulties are strongly linked to social acceptance and the quality of support available, rather than to neurodivergence itself (Pantazakos and Vanaken, 2023).

Counsellors and psychotherapists are well placed to offer meaningful support. Doing so requires more than good intentions, however. It requires us to examine our assumptions, adapt our practice and learn from the people we work with.

What do we mean by neurodivergence?

Neurodivergence is a socio-political and inclusive term for people whose bodyminds differ from predominant or typical norms. It is not a clinical label or diagnosis. Instead, it recognises that human cognitive, sensory, communicative and embodied variation is natural and valid.

Neurodivergence can include:

• Innate neurodivergence, including autism, attention differences, dyslexia, dyspraxia, dyscalculia and Tourette syndrome.
• Acquired neurodivergence, which may develop following brain injury, stroke or another neurological event.
• Mental health-related neurodivergence, involving cognitive, emotional or sensory processing differences shaped by experiences such as complex trauma, anxiety, depression, psychosis or dissociation.
• Other forms of neurodivergence, including changes associated with medication, substance use or other external factors.

This blog focuses on autism and attention differences, including people who identify with both. These neurotypes are frequently encountered in counselling settings and often co-occur. Both groups also experience significant mental health disparities (Kroll et al., 2024; Pantazakos and Vanaken, 2023).

Late diagnosis and the search for answers

Many clients arrive in therapy without a formal diagnosis or certainty about whether they are autistic, have attention differences or both. Some have spent years sensing that their experiences do not fit the explanations they have been given. Others may have encountered the language of neurodivergence online, through a friend or through their child’s assessment, and be tentatively applying it to themselves for the first time.

Clients may describe chronic exhaustion from masking, a lifetime of social confusion, difficulty sustaining attention, sensory overwhelm or repeated burnout that has not responded to the strategies they have tried. The therapist’s role is not to diagnose or rule out. It is to hold these questions with curiosity, normalise the client’s experience and support them in making sense of their history.

Diagnostic pathways can be long, inconsistently available and shaped by historical biases. Women, people of colour, people assigned female at birth and people who do not present with stereotypical traits have often been under-identified. Some clients will not have access to formal assessment, whilst others may choose not to pursue one.

Therapy should not depend on a diagnostic label in order to validate a client’s experience or justify adapting the therapeutic approach. Where a client’s account suggests that neuro-affirming adjustments may be helpful, those adjustments can be explored without requiring diagnostic certainty.

Difference, not pathology

A central shift in practice is to stop treating autism and attention differences as problems to be fixed. Autistic and attention-different ways of being are valid forms of human variation, not symptoms that should automatically be reduced or eliminated.

When an autistic client finds social situations exhausting, or a person with attention differences struggles to sustain attention on tasks that do not interest them, this is not necessarily evidence that something is wrong with the person. It may reflect a mismatch between their needs and an environment designed around neurotypical expectations (BAAT, 2024).

This principle also applies to communication. Autistic people and people with attention differences may process information, express emotion and communicate meaning in ways that differ from what counsellors expect. These differences do not indicate a lack of understanding or emotional depth.

Milton’s (2012) concept of the ‘double empathy problem’ is useful here. Mutual understanding between people with different neurotypes is a two-way process. When communication breaks down, it is more accurate to consider whether there is a mismatch between communication styles than to assume that the client is deficient.

The therapist therefore has a responsibility to create a space that can accommodate different ways of communicating and expressing emotion. A client’s presentation should not automatically be interpreted as detachment, avoidance or limited insight simply because it does not resemble a neurotypical expression of feeling.

Cultural humility and the therapeutic relationship

Cultural humility offers a useful framework for neuro-affirming practice. Developed by Tervalon and Murray-Garcia (1998), it places responsibility on the professional to reflect continually on power imbalances and take action to address them.

Hook et al. (2017) extend this principle to the therapeutic relationship by arguing that therapists should move away from an expert stance and recognise the client as the authority on their own experience. Pliskin and Crehan (2024) describe this in relation to neurodivergent clients as ‘neurocultural competence and humility’. This involves questioning anti-autistic bias and developing methods that respond to each client rather than applying a fixed model.

In practice, this means working through co-inquiry. Collaborate with the client to explore meaning, identify useful forms of support and develop goals that reflect their priorities. Many neurodivergent clients have spent years being told what to do, how to behave and what counts as normal. Therapy should provide an environment in which they can participate in shaping the work.

Language matters

The language used in therapy, documentation and professional discussion affects how clients are understood. The NICE corporate style guide identifies ‘autistic people’ as an important exception to its general preference for person-first language. This reflects evidence that identity-first language is preferred by the majority of the autistic community (NICE, n.d.).

In practice:

• Ask about the client’s preference and follow it consistently. Some autistic people prefer ‘person with autism’, whilst others prefer ‘autistic person’. People with attention differences may use terms such as ‘ADHDer’, ‘person with ADHD’ or other language.
• When no preference has been stated, identity-first language such as ‘autistic people’ and ‘people with attention differences’ may be appropriate.
• Avoid pathologising or reductive terms such as ‘suffers from autism’, ‘low-functioning’, ‘high-functioning’ and ‘normal’.
• Describe the person’s experiences, strengths, differences and support needs directly.
• Use affirming language in case discussions, supervision, clinical notes and reports. The language in a client’s file can influence how other professionals understand and support them.

There is less consensus about preferred terminology for attention differences than there is within the autistic community. The safest approach is to ask, listen and follow the client’s lead.

Adjusting your way of working

Neuro-affirming counselling is not a separate therapeutic modality. It is an adaptation of existing practice, informed by an understanding of how autistic clients and clients with attention differences may experience communication, sensory information, time, attention and relationships.

Communication

Adapt spoken communication to the client’s processing style. This may involve shorter sentences, concrete language, written summaries, visual supports or less reliance on spoken exchange.

Some clients need additional processing time before responding. Others may experience auditory overload when there are competing sounds. Communication preferences may also change according to energy, emotional state or sensory environment.

Helpful adjustments include:

• Pausing comfortably after asking a question and recognising silence as processing time.
• Offering written or visual alternatives to spoken reflection.
• Checking the client’s preferred communication mode and revisiting it when necessary.
• Recognising that communication styles may shift within and across sessions.
• Avoiding the assumption that limited spoken communication indicates limited understanding.

Spoken communication is one mode among many. Therapy should be shaped around the client’s ways of communicating, rather than requiring the client to adapt to a speaking-centred model (Jones et al., 2024).

Environment

Consider the sensory qualities of the therapy space, including lighting, noise, textures, temperature and visual complexity. Invite clients to identify what helps them feel comfortable and able to engage.

Some clients may benefit from fidget tools, movement breaks or the option to sit in a different position. Others may prefer a structured and predictable environment.

Avoid assuming that offering more choice is always more empowering. For clients who experience executive function differences or decision fatigue, too many options can increase cognitive load. A considered selection of choices can preserve autonomy without becoming overwhelming.

Structure and flexibility

Provide clear boundaries and a predictable session rhythm whilst remaining responsive to the client’s needs. Some clients benefit from knowing what will happen in each session. Others need space to change direction when their priorities or capacity shift.

Communicate the structure clearly and collaborate with the client to develop routines that support regulation. Predictability and flexibility are not opposites. Both can be offered when the therapist is transparent about the framework and willing to adapt it.

Neurodivergent identity

Therapy can provide space for clients to explore, understand and develop a positive neurodivergent identity. This may include processing the impact of masking, late diagnosis, stigma and previous experiences of being pathologised.

Masking involves suppressing or concealing innate behaviours in order to meet neurotypical expectations. It is common among autistic people and people with attention differences, and can contribute to exhaustion, burnout, shutdown and a diminished sense of self. Some clients have masked for years or decades and may not yet have the language, confidence or safety to stop.

Do not pressure clients to unmask. Instead, create conditions in which greater authenticity becomes possible. Remain attentive to signs of burnout, shutdown and overwhelm, including when they emerge during therapy, and adapt the pace or demands of the work accordingly.

Anti-oppressive practice

Examining how ableism shapes clinical practice is essential. Therapeutic models, diagnostic systems and professional frameworks have often been developed from a neurotypical standpoint and may contain assumptions about communication, emotional expression, productivity and appropriate behaviour (Peters, 2023).

Neurodivergence also intersects with race, gender, sexuality, class, culture, age and other forms of disability. These intersections influence how clients experience their identity, access assessment and support, and encounter therapy.

Neuro-affirming practice therefore extends beyond individual sessions. It includes advocating within services and organisations for accessible environments, affirming language and systems in which neurodivergent people are understood and valued.

Ongoing learning

Becoming neurodiversity-affirming is not a one-off training exercise. It requires continuing self-reflection, unlearning and engagement with developing understandings of neurodivergence.

Supervision should include space to examine assumptions about what constitutes healthy or adaptive behaviour, including how the therapist’s own neurotype may shape their perceptions (Pantazakos, 2023).

Bowers and Widdowson (2023) identify three common risks when working with neurodivergent clients: imposing neurotypical relational expectations, failing to recognise the impact of accumulated shame and interpreting neurodivergent communication through a neurotypical lens.

Active learning should include training, professional literature and lived-experience accounts from neurodivergent people. Learning from neurodivergent therapists, researchers and communities is not supplementary to practice. It is part of the foundation of ethical and responsive work.

Final thoughts

Neurodivergent clients deserve therapy that supports them to thrive without treating their fundamental ways of being as problems to be corrected. A neuro-affirming approach is collaborative, flexible, respectful and willing to question the assumptions built into conventional practice.

For counsellors and psychotherapists, this means listening carefully, adapting communication and environments, recognising the effects of masking and stigma, and remaining open to learning. It also means understanding that affirming practice is not an optional extra for neurodivergent clients. It is part of providing safe, accessible and effective therapy.