Why Standard Therapy Doesn’t Work for Neurodivergent People
Once I walked out of a session and realized I felt worse than before 😔 And it went on like that for six months!
Disclaimer: mention of traumatic experiences and suicidal thoughts
I still didn’t know that I had ASD and ADHD. But I had depression and, as it later turned out, autistic burnout that had triggered it. And on top of that, CPTSD, but that part I had always known for sure. At the time I had just started studying to become a psychologist, and I still didn’t understand a lot about myself. I thought that the more painful the process, the faster I would pull everything out, cry it all out, and be released. But I wasn’t getting any better. And that was despite taking antidepressants. Sometimes I started to doubt things when, after yet another session, I would lie curled up in a ball and howl out loud. And before that there had been another experience with another therapist. Once, almost the whole session was a meditation with visualization of pleasant places and childhood memories that made me feel good in the moment. But after it ended, I was sitting on the floor, sobbing, and thinking only about going to the kitchen and getting a knife.
These are the most severe cases. And I’m telling them not to scare you, but to warn you that you need to pay very close attention to your condition during therapy.
Of course, working with a psychologist is not always a pleasant process, but a psychologist should know about the window of tolerance (the level of nervous system arousal at which you still have access to your experiences, but do not drop out of the conversation and can regulate yourself, feeling safe).
And respond to any of your departures either into excessive emotionality or into dissociation, when your psyche cuts off access to feelings and it’s as if you are watching everything from the outside, or as if everything has become very unreal and viscous, slowed down.
That is, despite experiencing difficult feelings, you should feel safe. That is the therapist’s task. To understand you, to explore your inner world together with you, to create a comfortable and safe space where you can share and discuss all your most troubling topics. And one more thing: the therapist should notice if there is no progress, if things are getting harder and harder for you, and recommend that you seek medication support from a psychiatrist, because in some cases it’s impossible without it, and it will significantly ease your life and speed up the therapy process. And sometimes it will save your life.
After that long introduction, let’s move on to specific studies and numbers, as well as how the therapy process should be structured with a neurodivergent client. Forewarned is forearmed. And it will be easier for you to notice some red flags early on, discuss them with your psychologist, or seek a second opinion from another specialist.
What the research says
Let’s start with how much we need help in the first place. Up to 70% of autistic adults experience at least one depressive episode during their lifetime, and about 50% meet the criteria for an anxiety disorder. That means we turn to specialists very often. The question is what happens next.
We drop out of therapy more often than neurotypicals. Among adults with ADHD in randomized controlled trials, the rate of premature termination of therapy ranges from 26.6% to 50%. And that is in research settings, where people are deliberately retained. In real practice, the numbers are most likely higher. For comparison, among people with anxiety disorders in general, the dropout rate from CBT ranges from 9% to 35%.
Why do we leave? Among the most common reasons for premature termination of therapy, according to the specialists themselves: dissatisfaction with the type of intervention offered and a mismatch between the therapy and the client’s expectations. “This is not what I need.”
“I kept wondering: maybe the problem is me? Maybe I’m too rigid to heal. And then I started hearing the same words from other autistic people — people whom therapy retraumatized because it gaslit their living logic. People who were taught to doubt their own clarity.” — Lovette Jallow, Substack, 2025
Adapted approaches work better than standard ones, and this is proven. Interventions adapted for autistic people show higher effectiveness compared with standard approaches for anxiety and OCD.
But most specialists do not know how to adapt. In a 2023 systematic review, the lack of specialized training was named as one of the main limiting factors. One study participant, a practicing specialist, said: “I do not see myself helping this person because of my training. It would be a disservice.” In the Russian-speaking sphere, work with neurodivergent adults has only appeared relatively recently, as in many countries. That is why it is important to search for and choose specialists (both psychologists and psychiatrists) carefully, and to look at who actually works with neurodivergent people. Especially if you yourself are not yet sure about the diagnosis.
What exactly we face in standard therapy
The difficulties stem from several basic mismatches between how standard therapy is structured and how a neurodivergent brain works.
1. Most therapeutic techniques rely on your being able to track your emotional state in the moment, name it, and relate it to bodily sensations. Alexithymia and reduced interoception make this process difficult or impossible; feelings may arise with a delay, or you may feel something but be unable to differentiate what it is.
2. We are asked to do the things that exhaust us, and this is called treatment. Group formats, body-based exercises with strangers, homework, behavioral activation while in burnout. All of this requires resources we may not have. And when we say I can’t, or this makes me feel worse, it may be considered resistance. What kind of therapy is that.
Behavioral activation is a valid, evidence-based protocol; it really helps with depression. But not with autistic burnout. This is a syndrome of exhaustion after a chronic mismatch between what the world demands and what we actually have. The desire to lie down and shut everything out is not a symptom to be eliminated. It is a signal from the nervous system: I am overloaded, I need isolation, this is the only way to recover.
“The conviction that effort equals worth led me into work addiction. Personal boundaries were erased. The shame was so intense that even after diagnosis I avoided the company of other neurodivergent people” — Essy Knopf, 2025
3. Our behavior in the therapist’s office is read as a symptom. Being late and forgetfulness are “avoidant behavior” or “resistance.” Long pauses are “difficulties with contact,” a marker of avoidant or schizoid disorder. A lot of clarifying questions mean anxious attachment, hypercontrol, narcissistic traits. Breaking the frame is a sign of BPD.
In short, almost any neurodivergent behavior in a therapist’s office easily fits into a personality disorder template. Because the symptoms really do look similar. And distinguishing them is a separate skill that requires knowledge and experience.
A separate point: eye contact. If you do not look into someone’s eyes during a conversation, it means you are avoiding, not listening, hiding something. In reality, for many autistic people, direct eye contact is a separate cognitive task that competes with the task of listening and thinking. We often hear and understand better when we are not looking.
What lies behind all this: lateness and forgotten payments may be symptoms of executive dysfunction, that is, difficulties with planning, switching, and working memory that are part of ADHD and autism. Long pauses before answering may be monotropic information processing, when the brain goes deeply in one direction and switches slowly. Lots of clarifying questions? Literal thinking and a need for accuracy and predictability. Unfinished homework is often a combination of executive dysfunction and the fact that the assignment seemed unclear or unsuitable.
4. We are taught to doubt what works as protection. Avoiding noisy places, the need for routine, stimming, retreating into isolation after overload — all of this is often interpreted as dysfunction that needs to be eliminated. Although for many of us these are adaptive strategies that really help regulate the nervous system.
5. We are not warned that a technique may not suit us. Box breathing, meditation, body scanning — for some neurodivergent people they trigger anxiety rather than reduce it. These techniques come from the toolbox for working with anxiety and panic attacks. Inhale for 4 counts, hold, exhale, hold. The logic is to slow breathing and activate the parasympathetic nervous system.
For some neurodivergent people, especially those with anxiety and increased sensory sensitivity, intentional focus on breathing does exactly the opposite. You start controlling an automatic process that was working by itself. The body reads this as a threat, and the anxiety only increases.
4. And most importantly: we often do not know that something is going wrong. Because all our lives we have been told “it’s like this for everyone,” “just try harder,” “you’re exaggerating.” We are very good at doubting our own sensations. We are bad at trusting the signal “this is making me feel worse.”
So what does work then?
A neuroaffirmative approach. The principle is: first the person, then the protocol. You, with your particular traits, are the starting point. Not a standard scheme that needs to be applied to you.
In practice, this means one thing: not every technique suits you. And that is normal. If box breathing causes panic — we remove it and look for something else. If focusing on bodily sensations does not work with reduced interoception — we adapt it or replace it. If behavioral activation intensifies exhaustion — then first we figure out what is happening, and only then move forward.
A good specialist does not cling to a protocol when they see that it is making a person feel worse. They change the tool. Because the tool is for the person, not the person for the tool.
Next time we’ll talk in more detail about which approaches can really be adapted for neurodivergent people and why.