When labels are liberating
Therapy Today, March 2022

In recent years, we’ve seen an increase in people identifying as autistic and embracing a neurodivergent identity. While there is also an increasing number of therapists who identify as neurodivergent, most autistic or neurodivergent clients end up working with neurotypical therapists. So as a profession, educating ourselves about clients’ diverse needs and offering a neurodiversity-affirming environment are key. As a member of several autistic support networks, I have come across many fellow autistics who have felt misunderstood, dismissed or undermined when they sought therapy. In this article, I outline best practice to ethically support neurodivergent clients with the environment and therapeutic relationship they need in order to flourish.

Defining neurodiversity

A good starting point is an understanding of what is classed as ‘neurodiversity’. Neurodiversity indicates a range of neurologies within a population, as in biodiversity. Those not fitting within the normative ‘neuro’ majority are considered neurodivergent; their brains have different neural pathways. Neurodivergence describes brains, sensory systems and behavioural traits that are different to the ‘typical’ majority. Most people are neurotypical, also known as the predominant neurotype, as their brains function and process information in the way society expects. However, the word neurodiversity tends to be misused and applied to a person, not a population.

There’s no singular definition of who is included under the neurodivergent umbrella. Some healthcare clinicians, outside of the counselling sphere, may separate ‘clinical’ from ‘applied’ neurodivergence. Applied neurodiversity refers to difficulties in skill application such as reading, as may be experienced by a client with dyslexia. Clinical neurodiversity relates to difficulties in communication: for example, those associated with autism. Acquired neurodiversity relates to conditions linked to illness or injury, such as a stroke injury.

As examples from a longer list, autistic folks and those with ADHD (often called ADHD-ers), and people with issues such as sensory processing disorder and dyspraxia may identify as neurodivergent. Clients with epilepsy and even personality disorders may also identify as neurodivergent. Here I will focus on autism, although the aspects covered within this article relate to just about any client falling under the neurodivergent umbrella, most of whom will experience regulatory challenges.

What is autism?

The term autism spectrum disorder, or ASD, widely used under the medical model, is discouraged by many folks within the autism community. While autistic people definitely have an individual spectrum of autistic experience and support needs, there’s no linear journey from being more or less autistic, which is how the spectrum is often interpreted – hence, ‘spectrum’ can be confusing.

Many autistic clients will have been immersed in a medical narrative in the course of diagnosis, with words such as deficit and disability applied to them. Helping them find a more positive narrative in the form of difference and uniqueness can help bolster conditions of worth.¹

‘I don’t do labels…’

As therapists, we’re ethically bound to promote client autonomy and self-governance. The profession upholds the value that gender and sexual identities are equal, for example. However, there is some way to go in terms of therapists recognising neurodivergent identities as equal to neurotypical identities. To explore this further, let’s consider an area of confusion within the neurodiversity narrative – labels.

Across talking therapies, social care and education, there’s a growing disparity in viewpoints concerning stereotyping. It may surprise you to know, for example, that the neurodiversity movement is in many ways pro-labelling, if labelling means identifying an individual’s support needs, respecting diagnosis and self-definition, and honouring an individual’s authenticity. For many neurodiversity-informed folks, a therapist saying that ‘they don’t support labels’ is a red flag that indicates they may not support personal autonomy if it doesn’t meet their own world views.

A counsellor or psychotherapist may not want to compartmentalise an aspect of a client (for example, the client’s ‘autisticness’) because they don’t want to ‘other’ them. But this may be ignoring client autonomy. One client, Elle,* was told by her therapist, ‘I don’t do labels’, when Elle tried to discuss the possibility of being autistic: ‘I ended up seeking a diagnosis without telling my therapist, because she had dismissively said, “Nooo, you don’t seem autistic,” when I’d spoken about it.’

There is an outdated belief that autism is a mainly male experience – Baron-Cohen originally proposed the ‘extreme male brain theory’, which suggests that female brains tend to socialise, male brains tend to systemise, and males are more likely to be autistic.² While it is recognised that autistic males and females do present differently (acknowledging that female autistic neurology is not based on assigned gender), the extreme male brain theory is increasingly challenged.

At present, autism is underdiagnosed in individuals assigned female at birth and in gender-fluid and non-binary people, people from ethnic minorities and people in lower socioeconomic groups.

Another autistic client, Carla,* was told by her therapist: ‘I don’t want you to be limited by your autism.’ ‘As if my limitations are just a matter of mindset!’ said Carla, with irritation. ‘It’s like you finally have an explanation for things, then [a therapist] dismisses it under the guise of not wanting it to “limit you”.’ This professional wariness of naming clients’ presentations and identities for fear of ‘putting the client into a box’ and stereotyping them is not uncommon. Psychologist and author Lucy Foulkes recently wrote in a newspaper article: ‘When you use a label to describe someone, you can turn a multi-faceted... character into a flat stereotype.’³ This is certainly one viewpoint; however, it is important that neurotypical therapists are not deciding on behalf of their client what is stereotyping and what is respecting autistic identity.

Otherness or belonging

This viewpoint of recognising non-normative diagnoses (or clients’ self-identification) as a ‘flat stereotype’ leads teachers, counsellors, psychotherapists, parents and many individuals to follow the premise that we shouldn’t label someone (for example, as ‘autistic’), as it doesn’t define them. But in fearing that we may ‘other’ a client, we may not recognise that this sense of otherness also represents belonging, especially when someone is marginalised. We all know that a psychological sense of fitting in, plus social support from a community, reduces the risk factors for loneliness and depression; therefore, belonging to a ‘tribe’ can be far from limiting. One client, Ben,* explains that rather than defining and limiting them, a diagnosis ‘expands who I am, not restricts it’.

It seems that neurodivergence is not yet widely regarded as a human rights issue like race, physical ability and gender diversity. Great steps are being made to educate individuals in all walks of life about racism, ableism and sexual orientation discrimination. Yet, neurodivergent folks are rarely afforded the same viewpoints by professionals; the same emphasis is not given to valuing a client’s culture (for example, autistic culture), and respecting their sense of belonging to a marginalised community.

Person-first language

The premise that autism doesn’t define that person extends to unhelpful language used by many therapists. As an example, person-first language, which is decreasing in popularity, describes the client ‘Jane’ as ‘having autism’. This is because ‘her autism’, in the eyes of the therapist, doesn’t define her if, for example, she’s also a mother and a teacher.

But what if Jane is also black? She wouldn’t be described as ‘having blackness’ – and being a black mother does define her. And what if Jane were blind? Would she ‘have blindness’? No one would suggest that being blind would not affect and steer Jane’s perceptions of the world and how she navigates it. Thus, identity-first language – such as ‘Jane is autistic; Jane is black; Jane is blind’ – is widely preferred by the neurodivergent community (although not exclusively! Therapists should always check their client’s preference).

By using identity-first language and not imposing our own world view of neurodivergence on a client (for example, the dreaded ‘You don’t look autistic’, or ‘We’re all a little bit autistic, aren’t we?’), counsellors and psychotherapists can truly support neurodivergent clients on their therapeutic journeys. Alison Jones is a neurodivergent, person-centred counsellor specialising in neurodiversity, anxiety and trauma. She reminds us that our ethically advised openness to clients’ self-definition should also extend to clients self-identifying as neurodivergent without a formal diagnosis. ‘Knowing you are neurodivergent and having it confirmed via a diagnosis are often very different things. A diagnosis can be a huge part of a person’s identity, but there are ripples with work, family and friends that challenge one’s core. Clients can feel frustrated and not enough, leading to masking [putting on a front to appear more neurotypical] and feeling ashamed. It is therefore important not to dismiss a client’s self-definition with patronising tropes such as “We’re all a little bit autistic, aren’t we?”’ Alison says.

Steph Callaghan, a therapist specialising in creative, holistic counselling and trauma therapy, agrees that counsellors must help clients embrace their neurodivergence, even if it is self-identified. ‘As an autistic person, I have been personally told by a therapist: “We don’t do labels in this room.” I found it very hurtful. Having an autism and ADHD diagnosis later in life was hugely validating – it is not a label for me, it is a way of being. Neurodivergent clients have a difference in the way they think and communicate, not a deficit,’ she says.

Not all labels are helpful, however. Describing an autistic client as ‘high functioning’ or ‘low functioning’ is now considered unhelpful, as it generally decries the individual’s struggles or strengths. It is better to name co-existing conditions that increase their support needs. Likewise, while people diagnosed with ‘Asperger syndrome’ may still identify with this diagnosis, it’s now considered a controversial term, not least because of Hans Asperger’s involvement in the Nazi eugenicist programme.

A final note on stereotyping and labelling: as therapists, a good way to check the appropriateness of our stance is to check our privilege. Do we have lived experience of neurodivergence (other than being a parent or partner of a neurodivergent person)? If not, then it isn’t our place to decide whether or not neurodivergence defines a client, or otherwise.

Of course, for every case where a therapist has misjudged their therapeutic narrative, there are many more who have got it right, whether by instinct or thanks to training or self-education. When therapy is truly diversity affirming, it can be a life-changing experience for autistic clients, helping us make sense of situations, relationships and experiences we have found challenging, and develop a stronger sense of self and pride in our identity.

* Clients’ names and identifiable details have been changed.