Ep 25: AuDHD Experience - Neurodiversity-Affirming Practice

 🎙️ Episode 25: AuDHD Experience - Neurodiversity-Affirming Practice

"Neurodiversity-affirming practice" is now on almost every clinician's website here in Australia and around the world — but what does it actually mean, and what should it look like in the room? In this episode, Aaron Howearth (Clinical Psychologist) unpacks affirming practice not as a marketing label, but as a genuine reorientation of how we understand, formulate, and work alongside neurodivergent people.

We start with the conceptual foundations: relocating difficulty away from the individual and into the mismatch between a person and an environment that demands they be someone they're not. From there we walk through the domains where affirming practice actually shows up — formulation, language, collaborative goal-setting, therapeutic-style fit, and environmental adaptation — using the five Ps formulation and plenty of lived-experience examples along the way. We then name clearly what affirming practice is not: relabelling old deficit-focused work, abandoning clinical reasoning, avoiding difficulty, or imposing an affirming frame on someone who hasn't asked for it.

Finally, we offer six practical markers you can use to tell whether the care you're giving or receiving is genuinely affirming — and an honest note on where the evidence base currently sits. As always, this is general educational information, not individualised therapy or advice.

In This Episode (Chapters)

• (00:00) Welcome and why affirming practice matters
• (01:30) What the research tells us — and where the evidence base is thin
• (03:00) Affirming practice as a reorientation, not a new treatment model
• (04:30) Relocating disability: the environmental mismatch
• (06:00) What we're actually trying to do in therapy (and what we're not)
• (08:00) The domains of affirming practice: formulation, language, goals, adaptation
• (09:30) Identity-first vs person-first language
• (10:30) The five Ps formulation, worked through as a personal example
• (15:00) Building treatment plans that align with the client's goals
• (18:00) Why suppressing natural ways of being costs us — masking, burnout, safety
• (20:30) Adapting the therapy itself: the person–therapy fit and homework
• (24:00) What is NOT neurodiversity-affirming practice
• (28:00) Six markers of affirming care
• (34:00) Outcomes: quality of life, not typicality
• (36:00) A closing reflection and an honest note on the evidence

Key Takeaways

• Affirming practice changes the work, not just the words. It's a reorientation of perspective, not a rebrand of deficit-focused therapy.
• Difficulty is relocated into the mismatch between a person and an environment that expects them to be different — not into the person themselves.
• The goal of therapy is a life that has value to the client and meets their goals, not normalising someone for what society expects.
• It is collaborative and consent-based: language, goals, and adaptations are co-designed, never imposed.
• It does not abandon clinical reasoning, the evidence base, or honesty — it holds those alongside genuine respect for the person.
• Homework that isn't getting done is a design problem to be barrier-managed, not a motivation failure.
• Six markers of affirming care: formulation names the environment; goals are client-led; goals don't ask for unhelpful masking; adaptations are individualised; language preference is asked, not assumed; outcomes are measured by quality of life.

A Note on the Evidence

Much of what's discussed today draws on lived-experience research and correlational data rather than randomised controlled trials. We don't yet have affirming interventions rated as evidence-based across systematic reviews — but the parallels with affirming practice in trans and queer communities, alongside strong lived-experience data, point clearly in this direction.

Disclaimer

This episode is general educational information only. It is not individualised or tailored therapy, assessment, or support. If you need support, please seek out an affirming clinician in your area.

Thanks for listening, and remember — we are different, not defective. 

Transcript

SPEAKER_00 0:00

Potty potty potty potty potty potty potty potty potty potty potty potty pod podcast. Potty potty potty potty potty potty potty potty potty potty potty potty pod podcast. We love an audio stim and self-acceptance. It's the Audi HD Psych Podcast. Hello friends, welcome back to the Audi HD Psych Podcast. I'm Aaron Howard, Clinical Psychologist, and we are different, not defective. Neurodiversity affirming practice is a bit of a catchphrase here in Australia and around the world. But what does it actually mean and what can we expect? We know that it's linked to improved outcomes for neurodivergent people and improved engagement in therapy. So what can we expect? What should we look for? And what can we do as practitioners? Today that's exactly what we're having a look at. We'll start by looking at the conceptual foundations of neurodiversity affirming practice. Then we'll look at the domains in which we can make change if we haven't already to be affirming. Then we'll have a look at what is not neurodiversity affirming practice. And finally, we'll finish up with how to tell if care is affirming. So, as always, this is general educational information only. This is not individualized or tailored therapy or support. If you do need support, please find an affirming clinician in your area. So we're not using neurodiversity affirming practice as a marketing label, though you'll see it on most people's practice websites these days. If your current clinician describes their practices affirming, this episode will really give you an idea of how to measure that and how to make sure that you're getting the best care for you. So I guess I want to start with a couple of statistics. In various research, 80% of autistic versus about 37% of non-autistic people had difficulty attending a GP to visit their doctor. In another study, about 130 autistic folk rated that affirming adaptations to their therapy were the most helpful changes, the most helpful parts. And then finally, just as a side note, we don't have any interventions rated as evidence-based across quite a large number of systematic reviews. So the data we draw on at the moment is primarily lived experience data or correlational data. So, affirming practice, it changes the work, not just the words we use to describe what we're doing. Affirming practice is not about doing the same old thing and just saying, I understand that neurodiversity is different brain types than in carrying on with the same way we've always done things. It's an actual change in the way we interact with neurodiversity and neurodivergence, the way we view it, and how we do our work as clinicians. There are a number of things to consider. So there are different modalities of treatment. Neurodiversity affirming practice is not a new mode of treatment, it's a reorientation of our perspective towards treatment with neurodivergent people. Historically, in our medical model, we're looking at autism spectrum disorder, attention deficit, hyperactivity disorder, learning disorder. Neurodiversity affirming practice reframes it not as a disorder inherent to my characteristics. We reframe it as difficulties that arise out of the conflict or the mismatch between the characteristics that I have and the characteristics that the environment expects me to have or demands that I have. So what are we doing there? We're relocating where the disability, where the difficulties are situated, put us in neurodivergent environments and we don't have disorder, but bring a neurotypical person into that environment and they're the person who doesn't fit, who doesn't meet the expectations of that environment. What does that tell us? That tells us that it's an environmental mismatch, not a problem inherent to us and our characteristics. So what are we trying to do with neurodiversity affirming practice? Rather than say you're broken and here's how we're going to fix you. You need to stop doing that thing that you're doing. You need to do more of the thing that you're not doing. You know, you need to stop stimming, you need to pay more attention. That's not what we're doing anymore. What we're doing in a neurodiversity affirming practice with in therapy is we're looking at not changing you for the sake of changing you to normalize you for what society needs. We are looking at helping you build a life that has value to you and meets your goals. If you stim, as I, you know, I've discussed in the past, I stim with my eyebrows. I do this for those on video or on YouTube. Um, I raise and lower my eyebrows regularly. The more tired, stressed I am, the more that happens. Uh, there's no real value in me changing that. So going to therapy to reduce that is just unhelpful. If I was in a role where, you know, I needed, perhaps I needed authority in some way, and that reduced my authority, and that was my goal, that would be worthwhile. But for the sake of just suppressing it because it's not what everybody else does, that's not what neurodiversity affirming practice is about. Neurodiversity affirming practice isn't about, you know, making you pay attention for an hour and a half without a break, if that's not your usual attentional style, unless it serves you. And in those situations, we would want to look at does the benefit gained from that outweigh the harms that come with that suppression of your natural state of being? We want to build a life that works for you. If there is no need to change the expression of those characteristics, then why would we? Rather, we can normalize them. We can repair the self-concept damage that's been done by unrealistic expectations of us and move forward with you not having to mask so much of who and what you are, with us not having to mask so much of who and what we are. So, what we're not doing is we're not abandoning the clinical work that we've always done. We're reframing it and we are placing the difficulties where they actually reside in an environmental mismatch. Now, in terms of the domains that where we affect or where we implement neurodiversity affirming practice, uh, and I'll speak from a psychological perspective here, but it would be quite similar across most healthcare. We're looking at our formulation, the language that we use, the goals that we're setting, collaborative, collaborative, oh, I love a collaborative early in the morning. The goals that we're setting collaboratively with yourselves as clients, and the adaptations that we can make in the environment to help make our environment person fit better. And I'll touch on quickly identity first or person first language, and that's always individually based. I use identity first, I describe myself as an Audi HDer or as a neurodivergent. I don't describe myself as a person with autistic characteristics and ADHDs. It's central to who and what I am, and it's a part of how I identify. So for those of you who aren't clinicians, the formulation part is it's the story that you tell us when you come in for your first session and we do the big long interview. We ask you all about your life and your history and your stresses and your strengths. We use that information to construct our formulation. I use a really, really simple one. We call it the five piece formulation. I'm looking for what's going on for you, the present your presentation, uh, what's happening for you right now that you would like to change? Then I look at predisposing factors, what's made you vulnerable to the difficulties that you're having right now that you'd like to change? Then I look at the precipitating factors, what are the triggers for the difficulties you're having? Then I have a look at, and this is probably the really important part, I look at the perpetuating factors. What is keeping you here in this situation? What's uh what's maintaining the difficulties that you're having? And finally, we look at protective factors. What are the strengths? What are the supports that you have in your life? And with that information, I have an understanding of how you got here, where you are, and particularly with the maintaining factors, what we can change for you, or what we can help you change, because we can't wave a magic wand. What we can help you change in your world to eliminate some of those maintaining factors. And often we do that with some of those protective factors, some of those strength and supports. So, a simple myself as a 20-something year old, I probably would, if I walked in for help, I would probably look at me and diagnose me with generalized anxiety disorder. At that stage, I was very undiagnosed. There's characteristics of autism and the impulsivity and associative thinking that underpins ADHD. So I'd probably make those diagnoses, diagnoses when they're causing difficulties. And then my formulation for predisposing would probably be now, I come from a neurodivergent family, so it runs in family. I've grown up in a neurodivergent household where attention spans were not typical. I grew up in a world where typicality was expected. So my self-concept as a young person was probably quite, well, it was quite impaired. I thought I was doing things wrong. I thought I was lazy. I thought I was unmotivated because that was the feedback I kept getting. Report cards could do so much better if just tried harder, you know, implying that I wasn't already trying hard to listen for 40 minutes at a time. So they're stresses, they're both vulnerability factors. But if I still live in a world that expects typicality from me, that's a maintaining factor as well. Then the trigger for me coming into therapy might be perhaps I've had a performance appraisal where I was at risk of losing my job. The maintaining factors, through a neurodiversity affirming lens, I would look at, okay, the environment expects me to do something without teaching me how to do that in a way that works for my brain. My treatment plan for me now would have been, okay, what are my interests? How can I tie my interests into the thing that I need to pay attention to, but really struggle to? Really great example. Thank you, all the GPs out there. I struggle with writing letters back to GPs who refer people to me. It's an administrative task, it's one that is really, really important, but it's it's just one of those things that my brain immediately wants to avoid. So when I have to do that, I sit down and I think about the benefit to the people who are going back to their GP to get their re-referrals and things like that. I think about how that helps the GP manage someone's health. And I use that as the motivation. Nobody taught me how to do that when I was a young person. So that would be a treatment plan born out of my neurodivergent characteristics, my vulnerability factors, the maintaining factors of not having the knowledge of how to anchor my attention. Pardon me. But then we have the treatment plan, but that needs to align with the person's goals. If I'm just creating a treatment plan because I think it's going to work for you, but it brings no real pragmatic value into your life, you'll have no desire to follow that treatment plan because you won't see the benefit in it. So we need to make sure that the goals we're using to build our treatment plan from are aligned both with what you need in your life or what our clients need in their lives, but also with our clinical knowledge and clinical best practice. Once upon a time, the goals, uh, and I'm not going to sit here and vilify ABA this time, but uh once upon a time, we looked at trying to change the expression of autistic characteristics, the natural expressions of our characteristics or our natural ways of being, to suppress stimming, to communicate in a typical way. Why is that problematic? We've talked about masking and burnout in past episodes because when I'm constantly suppressing parts of myself, the natural ways of being, it costs me energy. It costs me cognitive energy, and that impacts on my emotional state, that impacts on my overall energy, my risk of burnout, and then my risk of safety behaviors, uh safety-related difficulties. Why does that matter? Then I can't engage in life. If I'm burnt out, I can't engage in the social, social interactions that help refill my cup. I can't engage well at work. I'm at risk of losing my job and my financial security. If somebody came to me and they, oh, I don't know, perhaps there's something in your work role that requires you to be able to make eye contact, then we would consider something that helps you uh appear to have more eye contact. Really simple uh strategy that many of us use is looking between the eyes of the person so that we don't feel rude, because we're often told that look people in the eye, otherwise you look like a liar or you look rude. So if that serves you, and if it doesn't, my intervention there would probably be: can we get comfortable with saying to people I'm autistic and eye contact is not my natural way of communicating? So don't think I'm rude or being ignorant or dishonest. Uh, that's just the way I am. It's just my communication style. Uh you probably noticed I'm quite handsy for those of you who watch on YouTube. I move a little quite a lot. Some people can find that a bit much. It's distracting in quiet environments. There are two things I can do that I can suppress that, or I can create a space where those people who are a little bit more of movers like myself, we can move off to a side and just be ourselves and still pay attention to what's going on in the meeting or the learning environment. When we make the goals about the environmental fit rather than about changing the individual, we stop doing some of the iatrogenic harm where we're we're reinforcing the idea that neurodivergent folk are broken, and we start reinforcing the reality of the situation that it is an environmental mismatch. So, adaptation. We want to consider, you know, many psychologists work under CBT because it's easy to research, so there's a really big evidence base. The problem in many parts of the neurodivergent community with that is a lot of the homework that we need to do in CBT is inherently the things that we find it difficult to motivate for, partly because attentional differences, partly because I have a history of not being able to get the homework done, and then maybe I've failed tests and assignments, so that becomes a bit of a barrier for me to engaging. So just like the person environment fit should be the primary focus of our goals, with our therapeutic style, we also want to make the person therapy fit appropriate so that we get the best outcomes from the therapy we're providing and from the therapy we're receiving as neurodiversion folk. If I ask you to go home as an ADHD art who is always busy and, you know, commits to a lot of different things, and I'm asking you to do five hours of homework a week, and you come back into therapy, and I say to you, oh, you're not motivated, you're not engaged in therapy because you didn't get the homework done. I'm risking demotivating you from engaging with me at all, and potentially with any other psychologist. Sometimes, when you get that from a lot of different healthcare professionals, it becomes a barrier to neurodivergent engagement in healthcare. So we really want to adapt our therapeutic process as much as possible to the individual. And this is a standing practice in healthcare, certainly in psychology, where I just don't throw a standard 10-session CBT for social anxiety at every single person because that's not going to work for every single person. I adapt that to your particular experience, the contexts in which you have social anxiety. And so we want to do that broadly for neurodivergence as well. We want to say to people, we want to understand you well enough to know homework itself might not be the best for you to self-motivate. Can we get your partner involved for some social accountability? Can we set reminders? Is that how we get it done for you? Or can we accept that for some people, homework is just not the right thing for them in therapy? And good conversation, therapeutic conversation that builds insight might be more appropriate rather than expecting you to go out and do all of the homework that's difficult for you. So that's the end of that story for the adaptations. It's co-design. It is you as my client and I, or me as the client, and my healthcare professional working together to understand what we're getting from both sides and using that joint knowledge to build a treatment plan that actually works for me as a client, not for me as a professional. It's not about my convenience. So the next thing we want to have a little bit of think about is what is not neurodiversity affirming practice? Well, it's not just relabeling unchanged old school practices where I talk about how disordered you are and the deficits that you have and how you lack motivation or you lack the capacity to pay attention because, you know, I use that example all the time. That's just untrue. I can pay attention for just about for days sometimes if the the content is really interesting to me or a part of my interest. It's not just avoiding difficulty. It's not just doing the thing that's easier, easiest. And it's not just focusing on what I already know how to do. It's about having a chat to somebody. What's your sensory profile? Can I do something in my room to turn the lights down? Can I do something in the room? Or can I have an area in the waiting room where you might be able to, if you're overwhelmed when you come in, just have some quiet time. It's not abandoning our evidence base. It's not abandoning abandoning our clinical skills and our clinical reasoning to affirm somebody's narrative. That's the opposite of healthcare. We are humans, we are all biased. And when I live in a world that expects a different version of me to what I am, that experience can then bias the way I see things going forward. This is how negative emotion often works. So it's not just accepting someone's perspective when that can potentially be unhelpful. We're not invalidating people, but we're just we're not abandoning our clinical reasoning. We're keeping that to the fore, but we're also honoring and respecting the inherent value of the people in front of us, that those neurodivergent characteristics aren't an indication of you being broken. They're just they're just like me being expected to live to 100 kilos with my little stick arms here. It's an unrealistic expectation of me. And so expecting typicality out of neurodivergent folk is also, and we're letting go of that idea. It's not imposing a particular affirming framing on somebody who hasn't asked for it. It's not me turning the lights down without checking you, uh checking with you whether that's what you need. It's not me telling you that identity first language is right for you because that's neurodiversity affirming practice. Neurodiversity affirming practice is one, a changed perspective, but two, collaborative. It's what serves you. If you come in to me for EMDR for trauma therapy, maybe I don't need, maybe you don't want me to make it all about your neurodiversity, your neurodivergence, your autism, your ADHD, your learning difference. Maybe you just want to get the EMDR done and go. It's not me imposing my expectations on you. And I already mentioned it's not me suppressing or ignoring my clinical logic, my formulation. So finally, how can we tell if care is affirming? Well, there's six markers that I've got on my little list here. One is formulation, pardon me, my formulation needs to name the environment, the structures, and the systems that have expectations of me that are unfair. Systems that expect me to pay attention for an hour at a time when my attention span in this point in my life with my current stresses is 30 minutes at a time. It's an unfair expectation. And we name that. It is the mismatch between the environment and myself, not me being deficit and disordered. What are the goals? Are the goals led by my perspective on your neurotype or your characteristics more broadly? Or are our goals set by you and then informed by my clinical understanding, my understanding of psychology? Are our goals asking you to mask where it does not serve you? Not all masking is bad. I've had this, I had this conversation often. You know, I have resting vapid face. Uh when I'm thinking deeply, I do not mask at all. I don't have resting bitch face. I wish I did, that would be protective. I have the face of somebody who just looks like nothing is happening between their ears and I'm here for it. But am I trying to suppress that? Am I always putting that face on? Is that one of my therapeutic goals? Rather than asking the people around me to not expect me to not look vague or not expect, and I quote, resting bitch face to look so mean. Maybe don't read a face that has no intent of meanness behind it as mean. That's an environmental accommodation that we can make by having conversations with our staff members about that, not masking goals. There is a conversation in community that I happen to agree with, and that is therapy that asks neurodivergent people to mask their implicit characteristics, their central characteristics of themselves, is not unlike conversion practices for the trans community. It is asking us to suppress central elements of who and what we are and spend our lives trying to do that. And it's plain not okay. And it's it's it's harmful. It's very harmful. Side note, actually, there is mediating effects there, and some neurodivergent folk don't find all masking. Harmful, but that is context-specific and individual specific. So the adaptations that we try to make, the environmental accommodations and things like that, they're not standard. It's not a set and forget. Every neurodivergent person needs this, every autistic person needs this. We need to make sure environments aren't busy for every autistic person with sensory differences. We have to make sure that every room is completely clean without distractions for every ADHD who might get distracted. That's unreasonable. We are all individuals with different experiences that different stresses that impact on our cognitive functioning. And so it has to be individually tailored to you and your particular characteristics, your sensory differences or not, your cognitive differences or not, but also your daily life stresses that might be the same as a neurotypical person, which will amplify or interact with your sensory and cognitive differences that are related to your neurodivergence. In terms of language preference, I touched on this before: identity first or person first. I use identity first, but I'm not every neurodivergent person. We just need to ask people how do you prefer to be referred to? Do you prefer to be be referred to as an autistic? Um, I rather love the word autiste, don't know why, just do. I like being referred to as neurodivergent, but some people still, some people have internalized the idea that autistic is is deficit in disorder. And so that's not a comfortable frame for some people. So a person with autism uh is preferred by some people, but we just engage with individuals. Consent is key. Finally, uh, I touched on it before, homework is a design problem if it's not working, not a motivation problem. If I'm working with somebody and the homework isn't getting done, I barrier manage. What's barrier management? I ask the person, oh, why didn't we get that done? Was there something that stood in the way? And if it's something we can manage, then we work together to manage around that. Oh, I kept forgetting. Can we set some alarms? Can we ask mum? Can we ask my partner to remind me? Can we do the tedious thing in a room with other people? Can we go to a cafe to a library and tap into body doubling? We manage those barriers just like we do anywhere else. We make sure that we're we're centering the difficulty in the expectation, not in the person. And finally, outcomes. What are we looking for in outcomes? It's our quality of life. The outcome shouldn't be how typical can you be? The outcome for therapeutic, for therapeutic intervention should always be: do you experience a better life post-therapy? That's the goal. That's why people come into psychologists. That's why people come to healthcare professionals more broadly. I have a difficulty or some pain or something that I want to change about my experience of life. Is that changed? Is your life measurably and noticeably better at the end of it? And if it is, then arguably your therapy is neurodiversity affirming. So just as a little closer, affirming practice is the recognition that's what looks like a problem with us, what we really diagnose with deficit and disorder, is actually a problem with the expectations that the environment places on us, the demands of the environment versus what we bring to the party. If I and I do in my study here, I have cupboards up on high that as 177 centimeters tall, I can barely reach them. If you're five feet tall and I ask you to get things out of that cupboard, is that a problem with you or a problem with where I've placed the cupboards? One would argue it's an environmental problem, not a problem with a person who can't reach those cupboards. The same, I binge my stick arms before. I'm not a strong person, which is funny because I might be the only person of Mary Descent who doesn't have muscles. But I can't pick up the hundred kilo weight. In my usual world, I don't need to. If I go into an environment and I'm expected to do that, of course that's an unrealistic expectation for somebody whose arms are the size of, you know, a gym goer's fingers. We place the difficulties, the responsibility for them in the mismatch with the environment, not in the individual. So finally, and I think I touched on this at the beginning, it is important to note that the research base is quite thin in terms of the controlled trial base. A lot of the information that I've referred to today is from lived experience research or from correlational information rather than from randomized controlled trials, the gold standard of research when we're talking about clinical interventions. However, we can see from the research in the trans community and the queer communities that affirming practices make a difference. They make us understand ourselves better. They allow us to heal some of the damaged self-concept and self-esteem difficulties that we have from feeling wrong for so long. And they improve our well-being. Often, neurodiversity affirming practice can be linked to improved well-being via the relationship we have with our therapist or with our healthcare professional. We are different, not defective. And neurodiversity affirming practice honors that. Honors that we can change the environment rather than changing the person in many cases, except where that's your goal or my goal as a client. Well, thank you very much for your time again, friends. I hope this has been helpful and I will chat to you again next week. See you.