What does it mean to be neurodivergent-affirming in ERP?

Autistic adult advocates have shared important & valid critiques of behavioral therapies as an entire umbrella of treatment. Here are some practices that I personally think are crucial in ensuring that ERP is ND-affirming (and broadly human-affirming!) and least likely to cause harm. I aim to bring these approaches to all clients under my care. 

Affirming therapists have the client set their own anxiety goals:

The focus is not on becoming completely non-anxious or a societally-defined version of “healthy” / “normal.” The focus is on the client having the freedom to choose how they spend their time, vs. anxiety or OCD choosing for them. Additionally, I only work with adults (and sometimes teens) who are fully on board with exposure and understand the rationale for it.

Affirming therapists encourage clients to think about the long-term “workability” of changes:

Due to social pressures and internalized stigma, sometimes clients want to set goals based on norms or common expectations. These often seem reasonable in the short-term but are too draining to sustain in the long term. Common examples include “masking” in social situations to appear “normal,” suppressing “stims,” setting too many goals & not scheduling enough rest time, and relying on “productivity hacks” that wear off once their novelty fades. An affirming therapist supports clients in choosing goals that are in line with their long-term abilities, needs, and overall authenticity as a person. This often includes acceptance, self-advocacy, shame-reduction, and self-compassion work in addition to the ERP.

The affirming ERP goal is to practice valued actions & disengage from non-valued actions, vs. focusing on “habituation”:

When habituation (a decrease in anxiety over time, towards an eventual 0) is the main goal of exposure, there can be some drawbacks. The main critique is that it can lead to people chronically questioning themselves or doubting their own instincts if they feel they are not “supposed to be anxious” according to the therapist. This is especially an issue if exposure strongly emphasizes the “irrationality” of a fear. Another drawback is that if someone doesn't experience habituation as predicted, they may feel “stuck” in treatment and feel it isn't working. Instead of focusing on trying to eliminate anxiety, affirming exposures are framed as a practice that costs energy but helps a client build the ability to respond more freely and flexibly in stressful situations. That generally reduces the impact and drain of anxiety in the client’s long term life, but doesn't impose goals around feeling or thinking in a certain way.

Affirming therapists tease apart sensory needs & executive functioning concerns from the ERP work:

Autistic sensory differences & stims are more and more understood to be innate and these traits generally don’t respond to “treatments” designed to alter them. An affirming therapist does their best to work with clients to identify their relevant sensory needs, with the goal of accepting and accommodating these, NOT challenging them. This work is done throughout the treatment process. Similarly, many OCD-like behaviors in ADHDers are actually strategies that they formed to help manage their ADHD (such as compulsive double-checking, compulsive list-making) – affirming therapists work with ADHDers to figure out more sustainable approaches to these habits as part of their ERP, vs. pathologizing the behaviors completely. 

Many Autistic & ADHD people have social anxiety or other anxieties that “make sense” given their life history. Sometimes, CBT or ERP therapies include challenging thoughts as “irrational” or “not supported by the facts.” Affirming therapists spend minimal time on challenging thoughts, and more time on helping you think through pros and cons of how you face the fears you have, in the short-term and long-term. You get to decide if engaging in a specific anxiety-related habit, like rehearsing conversations or masking, feels “worth it” to you. You get to reflect on whether you want to keep those habits in all contexts, reduce them in certain contexts (like with friends vs. at work), etc.

Affirming therapists factor in the client’s traumas and minority stress:

Affirming therapists acknowledge interoception differences:

Interoception is the ability to feel sensations in your body, such as hunger cues or physical sensations of emotions. Sometimes, Autistic people have very low or very high interoception. I do my best to validate that lived experience and adjust the exposure approach if we identify that this is impacting you. However: Please note that if your interoception differences are very significant, a neuro-affirming Occupational Therapist is likely to be the most helpful care provider for that need!