This article was co-authored between David Gray-Hammond and Tanya Adkin
Trigger Warning: This article contains mentions of systemic mistreatment in the mental health setting, traumatisation, references to pathologizing theories and language, mention of cultural ignorance, and discussion of mental health conditions inlcuding cluster B diagnosis and misdiagnosis.
It seems to be common knowledge in the Autistic community that Cognitive Behavioural Therapy (CBT) by and large does not work for Autistic people. Lets dig a little deeper. The fundamental issue with CBT and other similar therapies is that they were designed around the predominant (or neurotypical) neurotype (Kelly and Farahar; 2021). These therapies were largely developed in the western hemisphere and therefore tend to adhere to western standards of ‘normal’. This presents the first of many issues, even before you consider the Autistic neurotype, not everyone will fit into those cultural standards.
According to NICE guidelines, CBT and related therapies should be adapted to be appropriate for Autistic individuals on a case by case basis, but the guidelines fail to discuss what these adaptations should be, based on input from Autistic individuals, and are instead somewhat generic in nature.
“Consider adapting the method of delivery of CBT for Autistic children and young people with anxiety”NICE Guidelines (2013, updated 2021)
The guidance then goes on to offer very little meaningful advice beyond emotional recognition training and simplification of tasks. It is quite clear that the Autistic community has not been consulted on this guidance.
The above example is part of a much larger and more pertinent question; is the application of neuronormative mental health theory and therapies actually largescale gaslighting of neurodivergent individuals?
Whenever we look at supports for Autistic individuals or common “deficits” cited for those of us with that particular neurotype, a lot of it is centred around difficulties with emotional recognition, alexithymia, and our inability to mentalise another’s emotional state (Baron-Cohen et al; 1985). In fact, theory of mind posits that our inability to mentalise the psychological state of others leads to deficits in social communication and the ability to empathise. Perhaps then it is easy to see where therapies informed by this research are already beginning to fail their Autistic patients.
Psychological therapies start from the position that there is one correct way of experiencing the world, this in itself is neuronormativity. It assumes that the neurotypical experience is the standard that all should be trying to achieve. So when the Autistic patient enters the room, the therapist will first attempt to understand the Autistic person through the lens of neuronormative thinking, and then try to force the Autistic mind into a neurotypical box, and in turn apply their understanding of neurotypical mental health, onto a neurodivergent mind.
This is a fundamental problem because Autistics simply do not think and experience the world in the same way as a neurotypical. They can pretend to through masking, but as previously mentioned in this series, that comes with a great cost to wellbeing (Gray-Hammond and Adkin; 2021). How do we even know that Autistic people have the same experience of emotion? This would go some way towards explaining the difficulty Autistic people experience when trying to explain their inner world using neurotypical two-dimensional descriptors.
We are teaching children to label their feelings as happy/sad/excited, etc, when in reality, who experiences just one simple emotion at once? How many different types of happy or sad are there? Emotion is complicated, so assuming that there is a standard experience of emotion that we should all fit into (regardless of neurotype) is not only ignorant but blatantly ableist.
If we apply the theory of monotropism (Murray et al; 2005) to emotion, it becomes even clearer why standard psychological interventions are not appropriate for Autistics. Put simply, the theory of monotropism suggests that core autistic experience is related to differences in attention. It suggests that autistic people’s thinking falls into detailed “attention tunnels” in comparison to the attention of those with the predominant neurotype, whose attention is less detailed but more easily split over multiple subjects also described as polytropic thinking.
So if we’re focusing on an internal feeling or emotion, then typical language used to describe neurotypical emotion is not going to fulfil its purpose.
How many times have doctors misdiagnosed autism (especially in female presenting individuals) as Borderline Personality Disorder/ Emotionally Unstable Personality Disorder? How many times have Autistic people been prescribed medication for depression or anxiety when the problem was in fact Autistic burnout? Yet more evidence that neuronormative standards do not apply to Autistic experience.
This medical neuroprovincialism creates gaslighting. Applying neuronormative standards to Autistic people regarding emotional and mental health creates further suffering by further traumatising us, creating more masking, and in turn lowering our ability to cope and manage our mental wellbeing. Thus, we have the vicious cycle of patient-blame perpetuating itself around the premise that Autistics have an incorrect experience of the world, and that cycle makes our mental health worse more often than it improves it.
In truth, nobody experiences the colour green in the same way, at least not that can be proven. Experience of emotion is entirely subjective, two people rarely even look the same, let alone having an identical experience of their inner worlds. Solipsism tells us that we can not ever experience the world through another’s eyes or mind, yet here are the neurotypical masses telling us what we should or shouldn’t be feeling based on their own prejudiced standards of what they consider “normal”. Labelling us disordered when we can not fit into that restrictive worldview. To add insult to injury, they’re not even interested in asking us about our experience. They just push us through therapies that at best are mildly to moderately helpful, and at worst can retraumatise us.
We need to be consulted on what does and does not help us, outside of the setting of the neurotypical thought process. We need trauma-informed therapies (because we are hella traumatised by merely existing in society as it is). We need to guide our therapists on what we feel and experience by advocating for ourselves loudly and proudly, in a language that feels natural to us, instead of accommodating their lack of understanding. We need to present the idea that there is more than one way to experience feeling, and finally we need to accept that about ourselves and encourage others to do so.
Consciousness is not a one-size-fits-all. It is a dynamic and ever changing thing for the individual, and it is as unique as our DNA.
Baron-Cohen, S., Leslie, A. M., & Frith, U. (1985). Does the autistic child have a “theory of mind”?. Cognition, 21(1), 37-46.
Gray-Hammond, D. and Adkin, T. (2021) Creating Autistic suffering: In the beginning there was trauma. Emergentdivergence.com
Kelly, A and Farahar, C. (2021) Autistics, trauma, & access to therapy: Angela Kelly educates Aucademy. YouTube (video below)
Murray, D., Lesser, M., & Lawson, W. (2005). Attention, monotropism and the diagnostic criteria for autism. Autism, 9(2), 139–156. https://doi.org/10.1177/1362361305051398
NICE Guidelines (2013, updated 2021) https://www.nice.org.uk/guidance/cg170/chapter/recommendations#interventions-for-coexisting-problems