Neurodiversity and Psychotherapy

The Stigma of Difference

This article was originally written as a presentation to fellow members of the Association of Psychotherapists Aotearoa New Zealand (APANZ). Feedback at the presentations was that it could be useful to others, including clients, so I’ve chosen to publish it here.

Introduction

I want to start by grounding us in a couple of terms that I’ll be using throughout this article: neurodiversity and neurodivergence. These terms are often used interchangeably, but they actually mean different things, and understanding that difference is important.

The term neurodiversity was coined by journalist Harvey Blume in 1998 and popularised by Judy Singer, an autistic sociologist. She used it to describe the idea that there is a natural diversity in how human brains function, just like there is diversity in physical traits, personalities, or learning styles.

In that sense, neurodiversity is a population-level concept. It includes everyone: autistic people, ADHDers, dyslexic people, and neurotypical people as well. It’s a fact of human variation, a kind of biodiversity for minds.

Neurodivergence, on the other hand, is an individual-level concept. It refers to people whose cognitive styles diverge significantly from what society considers "normal," often in ways that are pathologised or misunderstood. So when I talk about neurodivergent people, I’m referring to people like autistic individuals, ADHDers, and others whose ways of thinking, feeling, or sensing don’t align with dominant expectations.

Put simply: neurodiversity describes the big picture; neurodivergence refers to those who live outside the norms that picture tends to privilege.

You may also notice that I’m mostly using identity-first language. For example, I say “autistic person” instead of “person with autism.” That’s a deliberate choice. Many neurodivergent individuals see their neurotype as an integrated part of who they are, not something separate or medical that they carry like a burden.

That said, language is personal and some individuals prefer person-first language. There’s no universal rule, and the most respectful approach is always to ask people how they want to be identified and then honour that.

One final note: the generalisations I’ll use here are not intended to stereotype. They’re intended to offer reflection points and patterns that can help us notice bias, question assumptions, and become more attuned to the lived experiences of neurodivergent people.

At the heart of this article is a focus on how societal narratives and clinical frameworks shape the way we, as therapists, understand, support, and sometimes unintentionally misinterpret neurodivergent clients.

We’ll explore where stigma originates, how it manifests in the therapy room, and how we can move toward more affirming, collaborative ways of practising. So with that foundation, let’s begin.

The Focus of this Article

For the scope of this article, I’ve chosen to focus on autistic people and ADHDers, two identities that fall under the broad umbrella of neurodiversity.

They are among the more commonly diagnosed neurotypes, and they also share many lived experiences. Both groups often struggle with everyday demands and are frequently misunderstood in social settings.

Autism and ADHD are both polygenic conditions, meaning they are influenced by many genes rather than a single cause. Genetic studies show that around 50 percent of the genetic factors involved in autism also underpin ADHD.

Despite this, clinicians were long trained to see them as entirely separate, or even mutually exclusive. Until the release of the DSM-5 in 2013, it wasn’t even permissible to diagnose someone with both conditions, no matter how clearly they displayed traits of each.

That DSM-5 update brought diagnostic thinking more in line with what gene research, and neurodivergent people themselves, have been saying for years. These are not opposing conditions. They are overlapping ones.

Many people living with this overlap describe themselves as having “AuDHD,” a community term that reflects a blended experience which doesn’t map neatly onto traditional diagnostic categories.

So while autism and ADHD remain distinct diagnoses, in lived experience the boundaries are often blurred. Most of the autistic people I know also have some ADHD traits. Misunderstanding that overlap has led to missed diagnoses, fragmented or absent support, and unnecessary stigma.

That’s why I’m bringing them together here. Not because they are the same, but because their connection is significant. Recognising that connection helps us support neurodivergent people more effectively.

It’s also important to emphasise that both autism and ADHD are highly heritable. Estimates place heritability rates between 70 and 80 percent, which is among the highest known. It’s not surprising that these traits run in families, even if they show up in different forms. One person might lean more autistic, another more ADHD, and a third might express something in between. But the underlying traits often thread through generations.

This genetic framing really matters. It reminds us that these conditions are not caused by parenting styles, trauma, vaccines, or the environment. Those things influence how someone experiences the world, but they are not the origin. Autism and ADHD reflect fundamental differences in how the brain is wired.

And yet for a long time, and still in some spaces, autistic and ADHD traits have been viewed through those same lenses. They were interpreted as signs of poor parenting, trauma, or moral weakness, and treated as something to be fixed, corrected, or even punished.

Autism, for instance, was long blamed on emotional neglect by cold, distant mothers. This was known as the “refrigerator mother” theory in the 1950s. The idea did profound harm, not just to autistic people, but to entire families. It particularly targeted and shamed mothers, reinforcing a pattern of blaming women for their children’s neurodivergence.

ADHD, similarly, was often seen not as a neurodevelopmental difference, but as a discipline problem. Children who couldn’t sit still or focus were labelled lazy, dumb, disruptive, disobedient, or just ‘bad.’ And behind those judgments were often assumptions about poor parenting, lack of structure, or moral weakness.

Both conditions were also heavily shaped by gendered expectations. Diagnostic criteria were, and often still are, based on stereotypically male presentations.

In autism, that meant a focus on externalised behaviours like social withdrawal or repetitive movements. In ADHD, it meant a focus on hyperactivity and impulsiveness, especially when loud, physical, or disruptive. These traits are more commonly observed in boys, not because they are more neurodivergent, but because boys are often socialised to express distress outwardly.

Girls and women are typically taught to be sociable, agreeable, and emotionally attuned. They are discouraged not only from being disruptive, but also from withdrawing, appearing odd, or struggling socially. As a result, many learn to mask by mimicking social norms, staying quiet, and internalising their distress. This has led to widespread under-diagnosis. Many were identified late, misdiagnosed entirely, or never diagnosed at all.

For autistic girls and women, this can lead to diagnoses like anxiety, depression, or borderline personality disorder instead.

For inattentive or distractible ADHDers, especially girls, being dreamy or disorganised was often overlooked as harmless or misread as compliance. Their behaviour was interpreted as quietness, shyness, or sensitivity, rather than as a sign of cognitive difficulty. As a result, their struggles went unnoticed until anxiety, burnout, or breakdown forced contact with mental health services in adulthood.

There’s a pattern here in that both autism and ADHD have been treated less like natural variations and more like personal or moral failures, whether of the individual or their parenting. That critical framing still shows up in subtle ways:

• “If only they tried harder…”

• “If only they made an attempt to fit in more…”

• “If only the parents set better limits…”

• “‘If only they could just manage their emotions…”

‘Normalisation’ Therapies

Even therapies have also often been rooted in similar ideas promoting normalisation.

One example is Applied Behaviour Analysis, a therapy developed in the 1960s by Ivar Lovaas.

ABA was designed to make autistic children appear more ‘normal’ by suppressing autistic behaviours like avoiding eye contact, or hand-flapping, or using alternative forms of communication, through a system of rewards and punishments.

The goal wasn’t understanding or support. It was compliance and conformity. The logic was: if they can suppress these outward signs of autism, the person can learn to pass better as neurotypical and thus make things easier for others.

Lovaas also collaborated with his supervisee, George Rekers, in the 1970s on what became known as the Feminine Boy Project, a form of early behaviour therapy that targeted young boys who showed signs of gender nonconformity or queerness. They were punished for playing with dolls, speaking in ‘feminine’ tones, or expressing affection in ways deemed ‘inappropriate’ for their assigned gender.

It’s important to say plainly: this was conversion therapy, aimed at eradicating both queer identity and gender diversity through behavioural conditioning.

And it was based on the same logic as ABA: that visibly different behaviour is a problem to be fixed. That if you can suppress what’s seen on the outside, you might change who someone is on the inside.

Many autistic adults who experienced ABA describe it as traumatic, not because of individual practitioners’ intentions, but because the implicit message was always the same:

“Don’t be who you are. Don’t move the way you move. Don’t speak or feel the way you do.”

This connection between behavioural control, identity suppression, and harm brings us to an important point of overlap.

LGBTQIA+ Intersectionality

Neurodivergence and gender and/or sexual diversity often co-occur. Autistic and ADHD individuals are significantly more likely than the general population to identify as LGBTQIA+, and vice versa. It is still not the majority, but the prevalence is 4-6 times higher.

We do not have any evidence that either one causes the other, yet shared experiences emerge: both groups face the pressure to mask and have aspects of their identity treated as problems to be fixed in order to make others more comfortable.

Both groups are often told, explicitly or implicitly, that in order to be accepted they must change the way they communicate, express themselves, or relate to others.

This overlap matters in therapy. When we work with neurodivergent clients, we may also be holding space for gender or sexual diversity. And when we work with clients from gender and sexual diversity, we may equally be holding space for neurodivergence. It is important to ask questions and remain attentive to the full complexity of identity and the ways it is shaped by marginalisation and the pressure to conform, which in turn leads to self-silencing..

Autism Stigma

Let’s look more closely now at autism-specific stigma, and how deeply it shapes the way autistic people are perceived, not just socially, but also in clinical settings.

At the heart of autism stigma is that autistic traits are constantly misinterpreted through a neurotypical lens. Differences in tone, movement, focus, or social behaviour are not treated as neutral. They are judged and often judged harshly.

One of the most persistent and damaging misconceptions about autism is the idea that autistic people lack empathy.

This comes from outdated psychological theories, especially the Theory of Mind deficit model, which suggested that autistic individuals couldn’t imagine or understand other people’s thoughts or feelings.

But the myth goes further than that. Autistic people are often assumed to be unemotional, cold, detached, or indifferent.

In reality, many autistic people describe the exact opposite. Not a lack of emotion, but intense emotional experience. Deep feelings, often overwhelmingly so. Strong attachments. Fierce concern for justice, honesty, and the wellbeing of others.

So what’s missing here is not emotion or empathy. It’s mutual understanding.

This is what autistic social psychologist Damian Milton calls the Double Empathy Problem: the idea that miscommunication happens both ways. Yes, Autistic people may fail to accurately perceive or interpret neurotypical communication. But neurotypical people often fail to accurately perceive or interpret autistic communication. Yet that failure is rarely seen as a deficit in them, rather this burden is placed entirely on the autistic person.

Their tone is labelled flat. Their emotional expression is called inappropriate or exaggerated. Their body language is judged as wrong or weird. Even when they’re in emotional pain, it’s often missed or dismissed.

Autistic people frequently report being ignored or invalidated by professionals when they’re struggling, simply because their suffering doesn’t look the way neurotypical people expect distress to look.

There’s also a strong stigma around sensory regulation.

Many autistic people avoid crowded or noisy environments, wear headphones, ‘stim’, or withdraw socially. This is not due to disinterest, but because their nervous systems are temporarily overloaded.

Stimming, short for self-stimulatory behaviour, is a term used to describe repetitive movements or sounds that help regulate sensory or emotional input. This might look like hand-flapping, rocking, tapping, humming, or repeating words.

These actions often help autistic people self-soothe, stay focused, or release tension. They're tools of self-regulation.

But in social contexts, these coping strategies are often misunderstood. They may be framed as emotional detachment, avoidance, or disinterest.

In reality, they’re not barriers to connection. They’re ways of staying grounded and safe in environments that are often overwhelming or hostile to sensory difference.

The result of these misreadings is often profound. Chronic loneliness. Emotional isolation. High rates of depression and anxiety. Not because of autism itself, but because of the long-term trauma of being misread, unseen, or assumed not to feel.

This doesn’t just harm relationships. It actively increases serious risks. Research shows that autistic people, especially those who are undiagnosed or unsupported, face much higher rates of suicidality than the general population, twenty to thirty times higher. And much of that risk is driven not by autism, but by the chronic stress of being misunderstood, excluded, or expected to mask all the time.

ADHD Stigma

Let’s turn now to ADHD, and the ways it’s been, and still is, deeply misunderstood.

While autism has often been framed as a social or emotional deficit, ADHD is usually framed as a character flaw. It is a condition still routinely interpreted through a moral lens. People with ADHD are labelled lazy, flaky, undisciplined, or simply not trying hard enough.

From a young age, many ADHDers are told they are too much: too loud, too messy, too impulsive. Or they are told they are not enough: Not focused enough, not organised enough, not disciplined enough, not capable of following through.

These traits are almost always judged against neurotypical norms of productivity and behaviour. Sit still. Stay on task. Finish your work on time. Don’t interrupt. Follow instructions.

School is often the first place where this breaks down. ADHDers who can’t meet these expectations are punished, shamed, or labelled defiant. Parents are often blamed for being too lenient or too inconsistent.

And for those with inattentive-type ADHD, especially girls and gender-diverse individuals, the struggle is usually invisible. They’re not disruptive. They’re drifting. Daydreaming. Zoned out.

This presentation is often misread as compliance, shyness, or underachievement. It is often missed until adulthood, and only recognised when anxiety, depression, or burnout forces bring someone into contact with mental health services.

By that point, many ADHDers have internalised thousands of critical messages. That they just cannot seem to do what everyone else can. That their failures reflect a lack of willpower or responsibility, not a different kind of cognitive wiring.

That internalised stigma does more that just erode self-esteem. It often leads to maladaptive coping strategies. Many ADHDers turn to substance use, self-harm, and acting out as a way of managing intense internal frustration, restlessness, or emotional dysregulation.

Not because they do not care, but because they’ve been given no useful framework for understanding themselves. Often, they have only ever been offered shame and punishment.

So again, we are not just talking about misunderstandings. We are talking about real psychological fallout. Years of invalidation, unrealistic expectations and mislabelling, that shape a person’s entire sense of self.

In the Therapy Room

Let’s talk about what can happen when history, stigma, missing or misdiagnosis follows neurodivergent clients into the therapy room.

Even in well-intentioned spaces, neurodivergent clients report their behaviours are often misread through a neurotypical frame, and those misinterpretations can deeply affect the therapeutic relationship.

Let’s start with autistic clients.

• If a client avoids eye contact, they may be perceived as evasive, dishonest, or emotionally disconnected.

• If they stim, by tapping, fidgeting, or repeating movements, it may be interpreted as distracting, disrespectful, or a sign that they’re not engaging.

• If they communicate too bluntly or literally, they may be seen as hostile, challenging, or lacking insight.

• If they have strong preferences around sensory environment—like needing dim lighting, silence, or consistent routines—that can be read as controlling, obsessive, or rigid.

In reality, these are coping strategies. They are ways of self-regulating and protecting nervous system overwhelm in the sometimes intense emotional experience of therapy. They are not necessarily signs of resistance, disrespect, or poor relational capacity.

Now let’s look at ADHD clients.

• If a client struggles to stay focused, moves around, or blurts things out, it can be misread as disinterest, lack of respect, or even narcissism.

• If they interrupt, go off-topic, or miss social cues, they may be labelled as impulsive, attention-seeking, or immature.

• If they forget to attend sessions, show up late, or fail to pay on time, they are often seen as uncommitted, disorganised, or even manipulative.

But again, these are not moral or personal failings. These reflect cognitive differences, specifically around attention regulation, time perception, and self-monitoring, all of which operate differently in ADHD brains.

When we misread all the above behaviours, we risk replicating the exact invalidation and shame that neurodivergent people experience everywhere else. And we risk reinforcing the self-esteem injuries that brought them to therapy in the first place.

The message they may take in is:

“You need to be more ‘normal’ to be worthy of being helped.”

And that is a tragedy.

So where do we go from here?

If neurodivergent clients come into the therapy room carrying years—sometimes decades—of internalised stigma, the work isn’t just about coping skills or behaviour change.

The work is often about rewriting their self-story.

It’s about helping them see that the things they’ve been punished, shamed, or pathologised for, such as intensity, sensitivity, focus, movement, and emotional reactions, are not evidence of being broken or disordered.

They’re signs of difference. And within that difference, there is value. There is insight. There are strengths.

A Strengths-based Perspective

The same traits that have made life harder in a world built around neurotypical norms are often the very same traits that can reflect deep cognitive gifts.

So let’s talk about those strengths. Not as a way to sugar-coat the challenges, but as a way to restore balance to how we view neurodivergence.

Starting with autism:

Autistic people often have powerful systemic thinking skills. They can see patterns, structures, and inconsistencies with incredible clarity. Many have an intense focus that allows for deep exploration and nuanced expertise in their areas of interest.

They tend to communicate with honesty and precision and often bring a strong sense of ethical integrity to their relationships and work. They challenge social norms not out of defiance, but because those norms often just don't make sense to them. That is a form of courage.

For ADHDers, the strengths are different, but just as real:

ADHD minds are often fast-moving, associative, and highly creative. They are driven by curiosity, tuned in to novelty, and able to think across boundaries. They see possibilities, connections and solutions that more linear thinkers might miss.

What is often framed as ‘impulsivity’ can also be boldness, spontaneity, entrepreneurship, and a willingness to act when others hesitate. And when ADHDers are engaged in something meaningful, their ability to enter hyperfocus can lead to bursts of productivity and insight that are unmatched.

Both autistic and ADHD people often share a deep sense of justice. They are sensitive to hypocrisy, unfairness, and harm. That sense of integrity may not always show up in conventional ways, but it is there, and it matters.

Again, this is not to deny the real challenges that come with being neurodivergent in a world designed for different brains. But helping clients notice, name, and value their strengths is often one of the most powerful antidotes to internalised stigma.

When they begin to see that their differences are not just a list of deficits, but a set of patterns, perceptions, and needs that come with strengths as well as challenges, that is when the self-story begins to shift.

And that shift is the beginning of something deeply healing.

Neuro-affirming Therapy

So what does this mean for us as therapists? What does affirming, neurodiversity-informed practice actually look like?

First, it means recognising that therapy isn’t just about helping neurodivergent people cope with their differences. It is also about helping them deconstruct the internalised stigma that says those differences are wrong.

It means naming the social and clinical narratives that have framed them as broken, disordered, or difficult, and offering new stories in their place. Stories that include challenge, yes, but also value, insight, and agency.

For autistic clients, affirming practice often means acknowledging the immense effort they have already made to understand and navigate neurotypical expectations, often without recognition, and at great personal cost. It can sometimes mean being a neurotypical decoder ring for confusing situations.

For ADHDers, this often means helping them lean into their strengths: their creativity, energy, responsiveness, and passion. It might mean helping them reframe impulsivity as decisiveness, distractibility as environmental awareness, or restlessness as movement-based regulation.

And critically, it means supporting them in finding environments that work for their kind of mind. That might mean different workspaces, routines, relationships, or sensory settings. Environments where they do not just survive but thrive.

Rather than teaching them how to ‘pass,’ the therapeutic role is about helping them name what they have already been doing, recognise the toll of constant decoding and masking, and support them in choosing when and how to engage on their own terms.

This might include unpacking social confusion or burnout, making sense of relational dynamics, or identifying environments where authentic expression feels safer and others where it does not.

It also means validating their sensory needs, their communication style, their way of moving through the world. These are not obstacles to fix, but valid expressions of a different neurotype.

For both groups, affirming practice means helping them develop the language and confidence to advocate for their needs. That might be in relationships, workplaces, education, and yes, even in therapy.

Because when those needs are met, rather than dismissed or pathologised, neurodivergent people often begin to flourish.

And when they can say:

“I don’t have to apologise for how I think, feel, move, or exist. I just need the right conditions to be me.”

That is when therapy starts to become a space of real healing.

Conclusion

So to close, I want to leave you with one core idea:

Neurodivergent people are not broken.

They’re not failed versions of neurotypical people. They’re individuals navigating systems, environments, and assumptions that were never built with their minds in mind.

Therapists have the power to create a space that offers something different.

Not a space about correction, but about curiosity.
Not about conformity, but connection.
Not about masking, but meaning.

Every behaviour is an attempt to cope, communicate, or connect—even when it doesn’t look the way we expect.

So that’s enough from one mind. Now I’d like to open up the space for questions, reflections, lived experience, and reverie and to hear from all your diverse minds.