Neurodivergent-Affirming Clinical Practices and Psychological Safety.

IMPORTANT: This blog is not a substitute for therapy, but provides evidenced-based education for the purposes of self-help, or to compliment the therapeutic process. ​ ​This blog is non-monetized.

By Christina Crowe, RP, Validated Clinical Supervisor (S-Cert.) OAMHP

We therapists tend to come into our profession assuming our fellow mental health clinicians, charged with improving the mental health of their clients, would naturally be very good at establishing psychologically safe environments. Therapy is a ‘safe space’, right? Yet across the healthcare landscape, in mental health care in particular, people report they have often felt quite unsafe. How can that be?

One of the defining competencies of psychotherapy practice is referred to as ‘safe and effective use of self’ (SEUS). This simply refers to how therapists use their own experiences and understanding of themselves to help their clients. It’s about being aware of how our own thoughts, feelings, and behaviours affect the therapy relationship, and using that self-awareness for the benefit of the therapeutic work.

The ways therapists get good at this are varied, but can include engaging in their own personal psychotherapy, taking courses on use of self and being aware of the impact of their own experiences of personal family history and dynamics, anti-oppression and diversity, power dynamics, relational boundaries, experiential practice as client or interpersonal relationship development. Others may have engaged in a guided and reflective Indigenous practice, such as the four directional way.

Lived experience overall is often a sought-after characteristic when someone is looking for a therapist – someone who truly knows what you have been through can be incredibly healing. Lived experience is an equalizer of sorts, one that could contribute to lessening the power dynamic between clinician and client, that strengths the therapeutic relationship.

But what happens when unspoken power dynamics end up causing (unintentional) harm?

It’s impossible to talk about neurodivergent-affirming therapy, and therapy workplaces, without also talking about psychological safety.

The connection is multifaceted and deeply rooted in creating an inclusive and supportive environment for both clients and therapists. Professor Edmondson’s original research from 1999 defines psychological safety as an environment where people feel secure in expressing their thoughts and feelings without fear of negative consequences. Originally studied in medical teams within hospitals, this applies to the therapy session room as well, in the space between therapist and client.

A deep understanding of this is crucial for fostering emotional engagement, productivity, innovation, and commitment within a therapeutic relationship, as well as within a helping organization.

So what exactly are ‘neurodivergent-affirming’ practices?

Neurodivergent-affirming care is not just about individual interactions; it’s a form of cultural competence embedded within professional practice. Just as clinicians adhere to ethical and legal considerations, they must also integrate neurodiversity-affirming principles into their approach. Self-awareness and self-advocacy are the dynamic duo in the world of therapy.

Neurodivergent-affirming practices involve recognizing and validating neurodivergent identities (which can be acquired or heritable/neurodevelopmental), such as those of people with ADHD, autism, dyslexia, and other conditions, as natural variations of the human experience, rather than pathologies to be cured. By fostering a sense of agency and independence in our clients, therapists can help people build the skills and resilience needed to thrive in a world that may not always understand them.

Being neurodivergent-affirming does not mean we cannot or do not address, treat and manage the very real pains that come along with ‘symptomatic’ periods of time in a diagnosis such as ADHD for example. But all forms of treatment are absolutely tailored to the person, their strengths, their values, their life circumstances and where they want things to go.

As a clinical supervisor, the two places I often see therapists unknowingly misstep are around micro-aggressions (including ableism – more on that below) – both toward and received from clients and other colleagues, and client autonomy. To avoid delivering micro-aggressions, therapists must be mindful of the language they use and the expectations they set in the early stages of forming the therapeutic relationship. Micro-aggressions, whether intentional or not, can deeply impact the therapeutic relationship and hinder progress.

Intersectionality is a primary principle for a reason — when we do not see all of one’s identities, we do not see the whole person. When we don’t see the whole person, we can end up reinforcing barriers, discrimination and unfair expectations, standards and norms. When we don’t see the whole person, we are missing the context that we need to understand and support someone. We also cannot challenge neuronormativity without challenging cisnormativity or heteronormativity, and we can’t dismantle ableism without dismantling all forms of oppression.

Like all people, neurodivergent brains may have different sensory sensitivities or communication preferences. The difference is they have grown up in a world that continuously tells them they are somehow wrong for it. Affirming care involves acceptance of these preferences and needs, to ensure an inclusive and effective therapeutic environment.

Neurodivergent Therapists

Therapists who are neurodivergent themselves encounter the same microaggressions (and some would say, full on aggressions) throughout their training, and also in their clinical practice.

Some of the consequences of their experiences include:

  • Feeling a deep sense of imposter syndrome after surviving academia or ’ivory tower’ discrimination, and even symptoms of workplace associated PTSD,
  • Fear-based work behaviours to ‘keep up’, coupled with fear of asking for accommodations (+ willingness to do it repeatedly despite the challenge of articulating what they need),
  • Underemployment, under-achievement, lower earning potential,
  • The struggle to conform with Regulatory College regulations, or feel aligned with Associations, and NT/Allistic workplace cultures or practices (like how to make sense of the changing landscape around ABA for example).
  • Isolation, workplace conflict and/or shame in dealing with how their own symptoms impact them at work (how things like rigidity, inflexible thinking, challenges prioritizing, differing concepts of ‘teamwork’ show up),
  • The painful experience of living with ableism[i], self-stigma, and worst of all, internalized ableism (when someone discriminates against themself(!) and other disabled people by holding the view that disability is something to be ashamed of, something to hide, or by refusing accessibility, support or treatment where relevant).

An important caveat: just because your workplace feels psychologically unsafe doesn’t mean your colleagues or are boss are intending it to be so. To be clear, it IS the responsibility of leadership to make the first move to explore, examine and lead these conversations. However, psychological safety isn’t about an environment that doesn’t challenge people. It’s about a balance of challenge (stress) and safety (you feel supported). Psychological safety only works if everyone is willing to take the risk to speak up. Figuring out what you need to get to that place (what does emotional safety mean and look like to you?), and how to communicate it effectively, becomes the ever-evolving individual work.

For everyone involved, this involves a commitment to continuous learning and unlearning, challenging internalized biases, and adapting therapeutic approaches to meet the ongoing needs of their neurodivergent clients. This goes beyond a standard lens of ‘person-centred’ care. Arguably every ‘intervention’ is tailored to the person in front of us, regardless if we are experts in that person’s health condition – generally, we can trust that the client is.

What is different about neurodivergent conditions is that the therapist needs to know more about the basics of what it means to be neurodivergent. The culture of our work has evolved to blame the client for their mental health struggles and historically, clinicians have received inadequate training, blatantly incorrect training, insufficient supervision and consultation, which is why there is such a groundswell of ‘late-diagnosis’ (meaning, the proper diagnosis was actually missed in childhood) today. The problem is many of these symptoms almost entirely overlap with standard presentations of anxiety, depression and everyone’s fave, ‘it’s trauma’. So that is what get’s treated, and the ADHD in this case, remains unexamined, symptomatic and as the data demonstrates, ultimately tragic for the client.


We know a supportive workplace culture that values diversity and inclusion enhances job satisfaction and reduces burnout. Therapists doing their own self-awareness and acceptance work, contribute to and benefit from, working in an increasingly psychologically safe workplace, which will also organically begin to address issues around underemployment, understanding what ‘accommodations’ (and inclusivity) really mean, and promoting their own organization’s psychologically safe culture.  

It might be hard to know where to start. Whether you are reading about this from your own perspective as a neurodivergent therapist, of that of a colleague, a client in therapy, a patient yourself, a clinical supervisor, or a clinical director responsible for the work experience of a team of therapists, attending to your own continuing education and competency goals for could include study on areas like these:

  • Intersectionality: Paying attention to neurodiversity is as important as paying attention to gender, race, education or religious preferences, and essential for providing comprehensive support. Recognizing how factors like gender, race, and sexuality intersect with neurodivergence, sheds light on your teams experience of systemic barriers and discrimination.
  • Developing Individualized Treatment Plans: Gone are the days of cookie-cutter treatment plans. In neurodivergent-affirming therapy, it’s all about customization. By developing individualized treatment plans that consider each client’s specific strengths, challenges, and goals, we can create a roadmap to success, as unique as the individual themselves. This personalized approach ensures therapy is not only effective but also empowering.
  • Educating Clients and Colleagues on Neurodiversity: Knowledge is power, and in the realm of neurodiversity, education is key. As therapists, we have a responsibility to not only support our clients but also to educate our colleagues and the wider community on the diverse ways in which individuals experience the world. By exemplifying understanding and acceptance, we create a more inclusive and affirming therapeutic space for all.
  • Think about your physical spaces: Designing a neurodivergent-friendly therapy office is a bit like curating a comfy nest for your clients. Think soft lighting, cozy textures, and maybe even a fidget toy or two. Implementing sensory-friendly practices means being mindful of noise levels, smells, and other sensory inputs that could be overwhelming. Creating a safe and welcoming environment sets the stage for a positive therapeutic experience.
  • Systemic Change: Get involved with your relevant professional Association. True psychological safety and inclusion require systemic change within all-sized organizations, which is often part of the agenda of your professional association. This includes implementing strategic inclusion initiatives that go beyond individual efforts and address broader organizational culture, policies, and practices, with supportive and like-minded colleagues.
For the Therapists:
A few Do’s and Don’ts of Neurodivergent-Affirming Practice
Do’s:
  • Explore Diverse Perspectives: Encourage clients to define their own experiences and strengths, and then acknowledge and validate the wisdom of their lived experiences.
  • Presume Competence: Prioritize treating every individual as capable and deserving of respect, regardless of their neurodivergent traits. Re-examining neuronormative treatment goals (i.e., their appointment scheduling skills & your cancellation policy, or concepts like “social skills training”)?
  • Respect Autonomy: Empower clients to advocate for themselves and make informed decisions about their care. Consider how you assess and explore neurodivergent masking (also called camouflaging)?
  • Recognize Intersectionality: Consider how various identities intersect with neurodivergence and explore your own language around gender, NT, allistic, Autistic, ND, “levels of functioning’, monotropism, Autistic masking, camouflage,
  • Examine your business practices: Examine your missed /late session policy, reduce or eliminate overwhelming paperwork and points of access, rethink homework, accommodation’s v. inclusion. While CBT is an often recommended psychosocial intervention recommended for folks with ADHD, please bear in mind, this comes long after that person has had the benefit of the first line of treatment which is stimulant medication. CBT after meds have been optimized, go for it. Not before.
Slide courtesy of Christina Crowe, Skill-Building for Therapists: Creating a Neurodivergent Affirming-Practice, March 2024.
Don’ts:
  • Dismiss Experiences: Avoid minimizing or dismissing the experiences of neurodivergent individuals, and refrain from imposing neuronormative expectations (like asking your clients to stop fidgeting, moving around, or mislabelling their movements as ‘distractibility’ or some other shaming word).
  • Rely Solely on Labels: While labels can be informative when they specify gold standard treatment paths, they do not define or limit an individual’s identity or potential.
  • Neglect Self-Reflection: Continuously reflect on biases and assumptions to ensure a truly inclusive and affirming practice.
Slide courtesy of Christina Crowe, Skill-Building for Therapists: Creating a Neurodivergent Affirming-Practice, March 2024.
For People leaders

Are you a mental health workplace manager, supervisor or clinical director? Most places in the world include all brains – mixed neurotype environments. How do you know how to best support the people under your umbrella?

You can explore your own management practices and check in with yourself (and your team), on these points below. Do you:

  1. Promote an environment of open communication, cultivating a culture of psychological safety? Do employees or contractors feel they can raise issues, ask questions, and obtain additional support if required?
  2. Talk to your employees about how much autonomy versus direction they need to do their best work?  
  3. Have clear performance metrics and regular check-ins, so employees or partners have a routine way to report on their work progress?
  4. Appreciate your employee’s regular contributions to the team and recognize major milestones and noteworthy achievements?
  5. Ask your direct reports how you can help them be successful – what are the conditions in their work environment they need to succeed, and are you able to provide them?
  6. Does your workplace foster a mutually respectful and inclusive culture? How do you know?
Final thoughts

The connection between psychological safety and neurodivergent-affirming clinical practice lies in the mutual reinforcement of creating an inclusive, respectful, and supportive environment. It’s really important to distinguish between emotional safety and psychological safety, and between “safe spaces” and psychological safety at work. The latter is about being in an environment that is not afraid to talk about hard things, not a space that doesn’t allow hard things to come up. 

For clients, this means feeling validated and understood in their neurodivergent identities, which can significantly improve their mental health and therapeutic outcomes. For therapists, it involves working in a culture that values diversity and inclusion, which can enhance their professional well-being and effectiveness.

Overall, fostering psychological safety through neurodivergent-affirming practices benefits both clients and therapists, leading to more effective and compassionate mental health care. Finally, for therapists treating ADHD or Autism in any setting, it’s so important to have ADHD skilled clinical supervision and consultation. This means academic training, significant clinical experience and that the supervisors themselves engage in their own ongoing ‘supervision of supervision.’

Learn more by checking out some of the references listed below, visiting our own ADHD Resource Hub, the Canadian ADHD Resource Alliance (CADDRA), the Centre for ADHD Advocacy in Canada (CADDAC), or the Embrace Autism site.


References

Campbell, Fiona Kumari (2009). “Internalised Ableism: The Tyranny Within”Contours of Ableism. Palgrave Macmillan UK. pp. 16–29. doi:10.1057/9780230245181_2

Crowe, ​Christina. (2023, August 29). Neurodivergent-affirming classroom management: 3 perspective shifts for teachers. The Dig Deeper Blog. https://digalittledeeper.ca/neurodivergent-affirming-classroom-management-3-perspective-shifts-for-teachers/  

Curnow, E., Rutherford, M., Maciver, D., Johnston, L., Prior, S., Boilson, M., Shah, P., Jenkins, N., & Meff, T. (2023). Mental health in autistic adults: A rapid review of prevalence of psychiatric disorders and umbrella review of the effectiveness of interventions within a neurodiversity informed perspective. PloS one18(7), e0288275. https://doi.org/10.1371/journal.pone.0288275

Edmondson, A. (1999). Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly44(2), 350-383. https://doi.org/10.2307/2666999

Glyde, T. (2023, November 3). Therapists, are you harming your autistic and ADHD clients? (part One). London Central Counselling. https://londoncentralcounselling.com/2023/11/03/therapists-are-you-harming-your-autistic-and-adhd-clients-part-one

McVey, A. J., Jones, D. R., Waisman, T. C., Raymaker, D. M., Nicolaidis, C., & Maddox, B. B. (2023). Mindshift in autism: a call to professionals in research, clinical, and educational settings. Frontiers in psychiatry14, 1251058. https://doi.org/10.3389/fpsyt.2023.1251058

Moses, A. (n.d.). Neurodiversity affirming practice is not just for patients. Psychology Today. https://www.psychologytoday.com/ca/blog/thinking-about-becoming-a-psychologist/202305/neurodiversity-affirming-practice-is-not-just 

Neff, M. A. (2024, February 17). Neurodivergent affirming practice: Helping your clients accept their authentic selves. Insights of a Neurodivergent Clinician.

Neuroinclusion at work report 2024. CIPD. (n.d.). https://www.cipd.org/en/knowledge/reports/neuroinclusion-at-work

Roberts, J. (2023, November 7). Neurodiversity-affirming therapy: Positions, therapy goals, and best practices. Therapist Neurodiversity Collective. https://therapistndc.org/neurodiversity-affirming-therapy  


[i] Ableism is discrimination and social prejudice against people with physical or mental disabilities.

  • When people are assigned or denied certain perceived abilities, skills, or character orientations because of their disability,
    • In ableist societies, the lives of disabled people is considered less worth living, or disabled people less valuable, even sometimes expendable.
  • Neurodivergence refers to neurological differences, not mental health issues, though neurodivergent individuals may be at higher risk of mental health conditions.
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Picture of ​Christina Crowe, H.BSc. MACP, RP, (S-Cert) OAMHP (she, her)

​Christina Crowe, H.BSc. MACP, RP, (S-Cert) OAMHP (she, her)

Registered Psychotherapist, Validated Clinical Supervisor, ADHD Therapist & Coach Podcast Host The Christina Crowe Podcast Christina is a Canadian Registered Psychotherapist, a member of CADDRA's Advocacy Committee and relentless mental health advocate. Christina believes great mental health information should be available to everyone, loves creating content that makes invisible things VISIBLE and finding new ways to bring healing experiences to as many people as possible.

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