“My last therapist would accuse me of not trying to get better, but I was trying so hard. I kept telling her that the things she was suggesting just weren’t working for me, but she didn’t believe me.”
I have heard some version of this statement many times during my years of clinical social work, almost always from neurodivergent clients. In most instances, it seems like the therapist is viewing the lack of progress through the lens of avoidance. This makes sense, as avoidance is often the reason that clients do not follow through on therapy homework. Therapy can be difficult, and avoidance of uncomfortable feelings is common, especially if working through things like trauma, anxiety, or other issues that can bring up uncomfortable memories and emotions.
What if It’s Not Avoidance?
While avoidance if often the reason for lack of follow through, it is important to remember that it isn’t always the reason. If a client is consistently struggling with follow through, and claims that they are trying, it is important to believe them. Remember humanistic theories that encourage therapists to emphasize the client’s perspective of the world and emphasizes that clients are the experts on their own lives. This means that if a client says they are trying, but the tools or strategies are not working, you as a therapist should believe them and work to try other approaches that will work better for them.
In my own therapy practice, I specialize in treating neurodivergent clients and I have found that while avoidance is sometimes the reason for lack of follow through, more often, it is due to the fact that the client is neurodivergent and may have challenges or diverse needs that need to be taken into account. For example, a dyslexic client is more likely going to struggle with an activity that involves reading or writing. An ADHD-er is more likely to struggle with activities that require concentration like guided meditations. Autistic clients who struggle with verbal processing may not remember information if it is only given to them verbally. Someone with poor interoceptive awareness may struggle with activities like body scans. For these individuals, they will need alternative activities because no matter how hard they try, their disabilities will make these tools, which are helpful for many, difficult if not impossible for them to complete.
Neurodivergent People Are Overrepresented in Clinical Populations
In discussing the problem of therapists misinterpreting lack of follow through for avoidance in the neurodivergent population, a few factors must be explored. First, neurodivergent people are overrepresented in the clinical population. Lai et al., (2019) found that 70% of autistic people qualify for at least one mental health diagnosis and 50% qualify for two or more. Similarly, the Centers for Disease Control (2024) notes that close to 78% of ADHD-ers qualify for at least one mental health diagnosis.
Second, many high masking neurodivergent adults are not formally diagnosed due to a number of contributing factors. Henderson, Wayland, and White estimate in Is this Autism: A companion Guide for Diagnosing (2024), that as many as 1 in 5 individuals receiving mental health services are autistic. They cite a study by Nyrenius, et al. (2022) that found that nearly 19% of adults who were seen at a psychiatric clinic were autistic, but only .5% had a formal diagnosis prior to coming in for services.
Therapy Training Programs Do Not Adequately Prepare Professionals to Identify Neurodevelopmental Disabilities
So, while the neurodivergent community is overrepresented in clinical populations, and many adults are undiagnosed, mental health professionals are getting little training on the topic of neurodevelopmental disabilities, meaning that they are not adequately trained to look for it as a factor in treatment. One study reviewed the syllabi of counseling programs, and found that multicultural focused classes included disability as a topic less than 30% of the time. To be clear, this study was looking for topics on all categories of disability, not just neurodevelopmental disabilities (Emir Öksüz et al., 2020). Another research team called more than 8000 clinics across the United States and found that less than 13% of therapists had any training or experience treating autistic people (Cantor et al., 2020). With so little education and training related to neurodivergent diagnoses, it is no wonder that many professionals are not considering neurodivergence as a possibility when they encounter clients who seem like they aren’t following through on therapy recommendations.
Lack of Training on Neurodivergence Is a Chronic Problem, but Not the End of the Story
The problem of neurodivergent clients being misunderstood in therapy is so prevalent that there are resources like The Autistic Survival Guide to Therapy, written by Steph Jones (2024), an autistic therapist from the UK. Her book focuses on helping autistic people avoid negative experiences in therapy, and ensuring that they get the most out of treatment. The fact that the book is written not for professionals, but for autistic clients, highlights the very significant problem with how neurodivergent people are treated by a mental health system that often is not responsive to, or ever aware of, their needs.
As mental health professionals, we can be active in helping neurodivergent clients avoid negative therapy experiences by ensuring that we give feedback to our respective disciplines that training programs must to do better to include information about neurodevelopmental disabilities. We can also make efforts to obtain continuing education that focuses on this community.
Even if this isn’t an area of focus, all therapists are seeing neurodivergent clients whether they know it or not. Finally, when facing a client with consistent lack of follow through, it is important to consider that there may be reasons other than avoidance for this behavior. Next time when you see lack of follow through, consider that you may have asked the person, regardless of their neurotype, to do something that is not a good fit for them. Changing your thoughts about the client’s behavior may lead to a more effective therapy experience, which will benefit both the client and you as the professional.