Strengths-Based Approaches for Neurodivergent Clients: Fostering Self-Acceptance and Self-Advocacy
In recent years, the neurodiversity movement has garnered more mainstream attention as advocates push for acceptance and equal treatment for people with various neurological conditions (autism, ADHD, dyslexia, etc). It makes sense why more people than ever are talking about it— as of 2022, it’s been estimated that 15-20% of the world’s population is in some way neurodivergent. Considering how common it is for people to go misdiagnosed or undiagnosed, this percentage is likely even higher. As such, it’s become increasingly important to discuss how we can change social structures to be more inclusive and accepting of all people; this is especially true in the music therapy field, where many of the clients we see are neurodivergent. Everyone from clients to caregivers to clinicians could benefit from asking themselves: what is the role of therapy in the neurodiversity movement? How do we best support neurodivergent clients who live in a world that, while starting to talk about inclusivity, is still largely non-accepting?
Before answering these questions, it might be helpful to take a look at the different ways people look at neurodiversity:
Medical Versus Neurodiversity Models:
The majority of research and discourse is currently framed around the medical model (sometimes called the pathological model) of neurodiversity. In essence, this model centers on the beliefs that:
There is only one healthy and right way for a brain to function (the neurotypical way),
Neurological conditions such as autism or ADHD are disorders that only impair function, and
These neurological differences need to be corrected or cured.
Under this lens, being neurodivergent is a problem in and of itself. Care for clients prioritizes outwardly being more neurotypical, frequently without regard to how this actually impacts their well-being. Therapists who work under this framework may set goals for neurodivergent clients such as reducing stimming, increasing direct eye contact, or using solely speech to communicate. The medical model does not consider how these so-called “odd behaviors” may be beneficial to the client, or how the physical and social environments they live in can help or hinder them. These types of goals are frequently counterproductive and often harmful to the client, as it can teach clients that something is inherently wrong with them.
Recently, neurodiverse self-advocacy groups and allying clinicians have pushed for the adoption of the neurodiversity model. Unlike the medical model, the neurodiversity model posits that:
Neurodiversity is just like any other diversity– it is neither inherently good nor bad, just a different way of being that has it’s benefits and challenges,
The dysfunction attributed to neurological conditions is more often a result of systems, environments, and others not accommodating neurodiverse individuals than the condition itself, and
Care should be focused on supporting neurodiverse clients in living and fulfilling their goals “neurodivergently” instead of meeting neurotypical standards of being.
An example of the neurodiversity model in clinical practice is applying a strengths-based approach. A great example of this strengths-based approach is Rachel Dorsey’s “Goal Writing for Autistic Students” training for therapists. This resource is aimed at goal-writing for autistic school children specifically, but its principles also apply easily to clinicians working with any neurodiverse clients. Rather than “traditional” goal-writing that emphasizes behaving in neurotypical ways, Dorsey takes a “strengths-based” approach, prioritizing the client’s strengths, natural interests, and personal goals and values. Care aims to do “what best helps the autistic student thrive, autistically” (Dorsey, 2021). Examples of goals based in the neurodiversity model may include working on self-advocacy, functional communication (in whatever form is safe and effective for the client: speaking, AAC, gestures, etc.), and improving emotional and sensory regulation (again, in whatever form is safe and effective for the client, be it stimming, moving, using fidgets, etc).
Resonate and its clinicians advocate for the neurodiverity model and strength-based goal setting. We firmly believe that the clinic should be a place of neurodiversity acceptance and celebration. As therapists, our job is to support clients in being their authentic selves and pursuing fulfillment and wellness based on their strengths and values.
Prevalence of the Medical Model:
Despite growing support of the neurodiversity model, American society still relies on the medical model to understand, talk about, and work with neurodivergent people. The implication that neurodivergent ways of being are inferior is extremely ableist; this results in discrimination and lack of acceptance that has been linked with an increased rate of mental health issues for neurodivergent populations. Even the way respected institutions such as the National Institute of Mental Health (NIMH) and the American Psychiatric Association (APA) talk about neurodivergence— as “disorders” (an inherent flaw or problem) that require “treatment” to fix rather than a condition or disability that individuals can navigate with support— demonstrates the medical model’s pervasiveness.
As clinicians who seek to affirm and support neurodiverse clients, it’s important to ask ourselves: does care under the neurodiversity model help clients when they have to walk out the door into a harsh, non-accepting culture? How does supporting stimming and non-speaking communication help clients when institutions such as schools and workplaces still discourage those very things? How do we as clinicians create affirming, beneficial goals with neurodivergent clients that also set them up for success in a largely ableist society?
Towards an Answer:
One obvious and easy answer to this question is “teach clients skills that will help them avoid judgment.” If neurodivergent people will face discrimination for atypical behaviors, then wouldn't learning to obscure those behaviors to protect themselves be the best solution? This is a very common stance! An evaluation of ABA critiques published in 2022 by Justin Leaf and others defend this position as “an obligation to best prepare their clients for the world in which they currently live, which is, unfortunately, less accepting than desired.”
Ultimately, this approach teaches clients to mask. Masking is generally described as a process where neurodivergent people attempt to present as neurotypical by hiding atypical mannerisms or needs, mimicking typical behaviors in others, and/or overall obscuring the authentic self behind a more socially acceptable persona. People may mask to avoid social rejection or bullying, develop relationships with neurotypical people, or be taken seriously in professional settings. Masking can be both a conscious and unconscious process, and some people may mask more often than others.
On the surface, masking may appear beneficial. It is true that, oftentimes, people who are perceived as “different” are bullied, shamed, and excluded in our society. Some neurodivergent people do report benefits from masking when it comes to limiting or avoiding negative social situations and navigating neurotypical settings; however, far more research and anecdotal evidence suggest it has a detrimental effect on the masker.
Multiple studies have found correlations between masking and increased levels of stress, anxiety, depression, and suicidality. Many autistic people describe masking as a mentally and physically taxing process; managing your facial expressions, body movements, eye contact, words, tone of voice, and more, all while inhibiting your core reactions, ways of being, and sensory experiences several times a day (if not all day) is an exhausting process that, in many cases, leads to burnout. Encouraging masking is also linked with a lack of clear identity and low self-esteem, as it reinforces the idea that being neurodivergent is wrong and must be hidden away.
Is it worth teaching clients the “normal” way to sit in class or the “normal” way to talk to friends if the risk is long-term mental health challenges and exhaustion? Is it teaching clients to protect themselves, or to quietly reject their very being and experience while looking others in the eye and smiling?
Potentially Better Strategies: Self-Acceptance, Self-Advocacy, and Strengths
While it’s important to know what isn’t a helpful approach to goal-setting for neurodivergent clients, it doesn’t tell us what is; however, research and self-advocates can point us in the right direction. Recent studies suggest that self-acceptance and authenticity are linked with improved self-image, higher quality of life, and lower rates of depressive symptoms. For a group suffering from higher rates of mental illness and stress than the general population, this is extremely important. Equally important is teaching self-advocacy skills. Because institutions currently don’t consider neurodivergent experiences, the ability to advocate for oneself (such as asserting their needs and giving consent or refusal) is vital for neurodivergent people, especially considering that most forms of neurodivergent education and care focus on teaching clients complacency and obedience.
In addition to Rachel Dorsey, SLP and CEO of Therapist Neurodiversity Collective Inc. Julie Roberts also provides strong examples of goal-setting under the neurodiversity model. Both recommend embracing the client’s strengths, values, and personal desires when writing goals. On top of this, goals towards improving interoception (our understanding of internal sensory experiences, such as hunger, thirst, needing the bathroom, or being overwhelmed), emotional recognition and regulation, and knowing how to set and maintain boundaries will give clients the tools to advocate for themselves and pursue their own goals. For neurodivergent clients— and really, any client— the overarching aim should be to help them live fulfilling lives on their terms, not on others’ terms.
But what’s just as (if not more) important as supporting individual clients is educating their support systems and communities. It is ineffective and unfair to place the responsibility of fixing a systemic problem solely on an individual. Research suggests that, in addition to self-acceptance, acceptance from others (such as family and friends) and a sense of belonging is correlated with lower rates of depressive symptoms and stress. When interviewed, several autistic teens and adults expressed that having accepting friends made it easier to be authentic. While supporting individual clients in self-advocacy and resiliency during sessions is helpful, having that same support at home and from the people close to them is even more beneficial. A strong first step towards this is educating caregivers: what it means to be neuro-affirmative, what kinds of goals or expectations are ableist versus supportive, and more. Several resources are available for therapists and caregivers alike; the Autistic Self-Advocacy Network (ASAN), Neuroclastic, and the Therapist Neurodiversity Collective all have several educational articles and guides to being an ally to their neurodivergent clients and children and adults.
Conclusion:
It was 1979 at a feminist conference when poet Audre Lorde said, “For the master’s tools will never dismantle the master’s house. They may allow us temporarily to beat him at his own game, but they will never enable us to bring about genuine change.” She was criticizing the current feminist movement for continuing to discriminate and exclude based on factors like race and class while trying to end discrimination based on sex.
It was 2012 in a blog post (and eventually an anthology published by ASAN) when autistic educator, psychologist, and activist Nick Walker applied Lorde’s metaphor to the neurodiversity movement. Even if we are staunch supporters of the neurodiversity model, continuing to use the tools of the medical model— such as teaching masking skills, using language that places neurodivergent differences as deficits, and pressuring individuals to conform to neurotypical standards— will only reinforce the ableism the medical model is based on. Keeping self-advocacy, authenticity, and community education at the forefront of care can support neurodivergent clients lead self-determined lives despite the barriers of current institutions. This approach is more difficult, requiring more time and critical consideration; however, the benefits to clients, caregivers, and society at large, are definitely worth it.
Resources:
C.L. Lynch, “Invisible Abuse: ABA and the things only autistic people can see”: https://neuroclastic.com/invisible-abuse-aba-and-the-things-only-autistic-people-can-see/
DCEG Staff, Neurodiversity Statistics: https://dceg.cancer.gov/about/diversity-inclusion/inclusivity-minute/2022/neurodiversity
Eilidh Cage, Jessica Di Monaco, Victoria Newell, “Experiences of Autism Acceptance and Mental Health in Autistic Adults”: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5807490/
Eilidh Cage and Zoe Troxell-Whitman, “Understanding the Reasons, Contexts, and Costs of Camouflaging for Autistic Adults”: https://link.springer.com/article/10.1007/s10803-018-03878-x?utm_source=getftr&utm_medium=getftr&utm_campaign=getftr_pilot
Julie Roberts, “Why Perspective-Taking and Neurodiversity Acceptance? Part 2”: https://therapistndc.org/why-teach-perspective-taking-neurodiversity-acceptance/
Justin Leaf et al., “Concerns about ABA-based intervention: An evaluation and recommendations”: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9114057/
*Note: this article was referenced to explain how the medical model impacts goal-setting; Resonate does not support ABA and isn’t supporting the beliefs supported by the article
Louise Chapman, Kieran Ros, Laura Hull, William Mandy, “‘I want to fit in… but I don’t want to change myself fundamentally’: A qualitative exploration of the relationship between masking and mental health for autistic teenagers”: https://www.sciencedirect.com/science/article/pii/S1750946722001568
Nick Walker, “Throw Away the Master’s Tools: Liberating Ourselves from the Pathology Paradigm”, in ASAN’s Loud Hands: autistic people, speaking
Also available on her website: https://neuroqueer.com/throw-away-the-masters-tools/
NIMH, “Autism Spectrum Disorder”: https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd#:~:text=Autism%20Spectrum%20Disorder-,Overview,first%202%20years%20of%20life.
Rachel Dorsey, “Goal Writing for Autistic Students”: https://learnplaythrive.com/goals/
Podcast sharing the general ideas of the training: https://two-sides-of-the-spectrum.simplecast.com/episodes/the-neurodiversity-paradigm-strengths-based-goals-with-rachel-dorsey-xynj2Cqe
Sici Zhuang et al., “Psychosocial factors associated with camouflaging in autistic people and its relationship with mental health and well-being: A mixed methods systematic review”: https://www.sciencedirect.com/science/article/pii/S0272735823000934
Stephanie Watson, Christopher D. Costantino, “Autistic is Me”: https://leader.pubs.asha.org/do/10.1044/leader.FTR1.27052022.ableism-autism.12/full/