By Dr. Mark Zuccolo, The Neurodivergence Research and Education Society

In clinical practice, as well as in social settings, it is often necessary to provide an individual, a couple, or a family with a framework that can help in understanding, accepting and managing a diagnosis of autism spectrum disorder (ASD) in adulthood, or its non-clinical manifestation as neurodivergence (in individuals) and neurodiversity (in groups).
The task is more complex than presenting the individual with a simple disclosure of the clinician’s or the coach’s perception of what may cause certain behaviors and explain their consequences in the individual’s functioning and level of distress. This may in part be because ASD was originally identified as a childhood disorder by Leo Kanner, in Autistic Disturbances of Affective Contact in Baltimore in 1943 and by Hans Asperger, in Die “Autistischen Psychopathen” im Kindesalter in Vienna in 1944. Since then, autism remained a serious childhood psychopathology that, in subsequent analyses, was publicly labeled “autism” by Bleuler in a 1910 paper, who made it broadly known the following year with his monograph, Dementia praecox oder Gruppe der Schizophrenien (which more famously introduced the term “schizophrenia” to the world) (Haswell-Todd, 2015).

Thus, a stigma gradually developed over autism, which was often described and understood only as “severe autism (level 3) [in] children who require substantial support (e.g., 24-hour care), have severe deficits in social communication (e.g., little to no speech), and manifest inflexible repetitive behaviors that are severely limiting (e.g., hand flapping, twirling in circles)” (APA, 2013). The adults who were once those children continued to show significant impairment, thus perpetuating the notion that ASD was an incurable and scary mental health disorder with serious lifetime biopsychosocial implications.

Neurodivergence and neurodiversity, on the other hand, are not classified as mental health disorders, although in the popular mind they may often be conflated with ADHD, OCD, GAD, Social Phobia, and other psychotherapy- or medication-worthy conditions. In the presence of certain behaviors, as for example in conflicted relationships, e.g., in couples where one party is neurodivergent and the other is neurotypical, the need arises in counseling to find a non-clinical explanation and coach the couple toward a better way to manage their personality differences. The same situation occurs when an individual presents in counseling with social phobia or interpersonal difficulties. In many cases a clinical diagnosis can be made, and the client will benefit from a psychopharmacologic approach, but in other cases an evidence-based diagnosis cannot be made.

So, how to identify and explain the reason for the disturbances becomes the task of the clinician, who must be able to step outside the therapist role and step into that of behavioral coach. It is during this role transition, and in preparation for it, that the concepts of neurodiversity and neurodivergence must be properly presented in ways that overcome the stigma of autism. This is outside the scope of this paper, but countertransference and transference may create additional difficulties and, in some cases, may lead to a premature termination of the therapeutic relationship. Additionally, the presence of a co-occurring disorder, e.g., an impulse control disorder or an anxiety disorder, may create a more adversarial situation when the words autism or “on the spectrum” come up in the conversation.
It is in thinking about these situations, which have occurred in my clinical practice, that I would like to briefly explore the transformative adaptation of the six principles of Acceptance and Commitment Therapy (ACT) to form the framework in which to broach to neurodivergent clients and their loved ones the realities and challenges of neurodivergence, devoid of any clinical connotation and drawing a sharper distinction between it and any other co-occurring disorder.

Trying to mask, avoid or closely control life’s distressing experiences may cause more pain, stress, and negativity. It helps to challenge the notion that pain, stress, and negative thoughts or emotions should be avoided or not felt, except minimally. Equally as important is to challenge the notion that a difference in the way an individual’s brain processes information, or the way an individual’s special senses react to environmental stimuli should be considered a disease of the body or of the mind, or both. Neurodivergence does not work that way, and attention patterns, social reluctance, and the need to self-regulate the flow of information and sensory stimuli are just part of being human, a neurodivergent human.

According to ACT theory and adapting to neurodivergence, two ideas are the core of a better approach:

1. ACCEPT discomfort, pain, stress, and negative thoughts whenever they are APPROPRIATE for the circumstances you find yourself in. If it’s time to mourn, mourn. If it’s time to be in pain, accept it as justified. If negative thoughts come into your mind, let them pass through. If you have difficulties in making phone calls, use email or text. If you can’t stand the texture of strawberries while loving their taste, blend them into a smoothie.

2. COMMIT to accept the things you cannot change, develop the courage to change the things you can, and acquire the wisdom to know the difference, as in Niebuhr’s world-famous serenity prayer.

The six core therapeutic processes in ACT are contact with the present moment (be in the here and now), defusing (watch your thinking and separate or detach from your thoughts, images, and memories), acceptance (open up and make room for unwanted private experiences), self-as-context (“the noticing self,” or in everyday language, distinguish between the two distinct elements of the mind: the part that thinks and the part that notices), values (know what matters, i.e., what do you want to stand for in life? What do you want to do with your brief time on this planet?), and committed action (do what it takes, by taking effective action as guided by your values, including both physical action with the body, and psychological action within your inner world).

If we transform these core principles to disclose the phenomenon of neurodivergence to individuals and their families with the twin aims of reducing distress and conflict, and improving functioning, we may present them in the following way.

The Six Principles in Neurodivergence

ONE: In the present moment, your thoughts, feelings, sensations, memories, and perceptions may not accurately describe your reality.

First, the individual may be brought to recognize that thoughts, feelings, sensations, perceptions, and memories are cognitive processes (things that are produced inside one’s mind) as opposed to accurate representations of reality. Second, the perception of reality by a neurodivergent mind may be different than that perceived by neurotypical minds. Third, different means different, without unnecessary qualifications.
While this may seem obvious, for most people, whether neurodivergent or neurotypical, thoughts aren’t just thoughts. Instead, they are often viewed as moral failings, threats, orders, predictions, or objective and unquestionable truths. The neurodivergent mind may also see their different perceptions, sensations, and thought processes as “not like those of ‘normal’ people,” or signs that “something must be wrong with me,” or evidence of serious mental health disorders.
It is important to remind the client that thoughts are just thoughts, feelings are just feelings, sensations can be managed, reduced or avoided, and memories are frequently inaccurate. Instead of viewing the workings of the mind and any biopsychosocial difficulties as the sole basis of a negative view of reality, and therefore of the self, they should be accepted as part of a larger body of information and evidence upon which to assess, analyze, and make decisions.

TWO: Defusion, a word introduced by Scott Harris in his best-selling book, ACT Made Simple, Second Edition (2019) means learning to “step back” and separate or detach from our thoughts, images, sensations, perceptions, and memories. The full technical term is Cognitive Defusion. It is a way of stepping back and watching our thinking instead of getting tangled up in it.

THREE: Acceptance invokes the mindfulness-based practice of observing one’s thoughts, feelings, and behavior nonjudgmentally. It allows you to struggle with distressing thoughts, emotional pain, stress, unusual sensations, and other unwanted experiences without labeling them as “bad” “weird” or “wrong” –which can create even more distress and impede optimal functioning.

The neurodivergent clients may be coached toward an understanding of this type of radical acceptance as likely to produce better outcomes, and that they have and should give themselves permission to feel all feelings, think all thoughts (letting them pass through the mind without acting on them), sense all sensory inputs, and react accordingly. An acceptance approach rejects judgment, false labels, stigma, and prejudice, so that individuals can acknowledge and experience their feelings instead.

FOUR: In discussing the self-as-context, the therapist may explain the duality of the mind, i.e. the conscious and the subconscious (a Freudian idea), or that self-concept is made up of three distinct parts: ideal self, self-image, and self-esteem (a Rogerian formulation), or simply help the client distinguish between that part of the mind that observes and the part that processes or experiences, thus introducing the idea of metathinking, or thinking about what one is thinking about.

The self-as-context is the ability or skill to notice, which is another way of boosting self-awareness. More self-awareness, we assume, can in most cases lead to a better understanding of the self, one’s assets and liabilities, strengths and weaknesses, one’s own different way of processing environmental input and observing them in a nonjudgmental way.
Another way to explain this principle is that one’s deeper understanding of the self can be used as context to interpret life’s experiences, as in, “this is the way I am, and I accept it.” Everyone is thoughts, feelings, sensations, memories, and experiences, and much more than the sum of the parts. Embracing this idea brings the locus of control and keeps it firmly on the inside, instead of relying solely on external feedback to build a sense of self.

FIVE: Values, also understood by psychodynamic theory as governing principles, determine what is most important to the individual and how the person will want to live their lives. They subtly or overtly inform the actions we take and the behaviors we choose to engage in. In an often out-of-consciousness process, before we decide what to do and do it, we first decide if and how we want to do it.

Many clients may need to be more aware that values are not the same as goals. Having dreams or goals for one’s life are of vital importance, but the client may need some help in more clearly defining how to accomplish them. This is a matter of authenticity and genuineness. Will the clients still be satisfied achieving their goals in life if they continue to mask, deny, and lie about their true nature as neurodivergent? Many people would say no, because such obfuscations go against their values.

SIX: Finally, a commitment to actions that are in line with the five foregoing principles may represent the culmination of an effort that may have begun in childhood or adolescence and is only possible now, thanks to newly acquired skills, greater resilience in the face of adversity and rejection, and a stronger ego.

Therapy Techniques

Ultimately, the tasks of the therapist and coach is to instill hope, promote psychological flexibility, allow people to accept what they cannot change, and help them take committed action to change what is within their control. Some techniques that may be employed by the therapist and coach in individual or couple sessions are:

Value Clarification. Taking the time to determine what is most important and how the clients want to live their lives.
Trigger Identification. Many thoughts, feelings, and recurring circumstances make it difficult to make values-based decisions. Identifying them helps demystifying them.

Observational Skills. Curiosity should replace judgment when it comes to analyzing a situation, just before going into problem-solving. Observing with an attitude of “wanting to know” and “seeking to understand the options” can lead to better decisions.

Mindfulness. Mindfulness is one of the most studied and practiced ways to stay in the present moment. Encourage your clients to learn how easy it is to apply.

Self-compassion. Concurrent with a healthy dose of patience, it helps clients to accept the unavoidable fact that beliefs, behaviors and attitudes won’t change overnight. Skills take practice. Self-compassion and grace come very close to being virtues.

Co-occurring Disorders

Neurotypical and neurodivergent individuals, all human beings, may struggle with a variety of mental health disorders, including anxiety, depression, addiction, OCD, chronic diseases, PTSD and more. Once the neurodivergent individual comes to accept this characterization of his or her personality, the clinician may begin to treat these disorders, and the coach may refer to a clinician for treatment.