Neurodivergent Dread Versus Anxiety

Treatment is Different

Subject: Rethinking Anxiety Treatment for Neurodivergent Clients

Dear Colleagues,

With 30 years of experience in treating anxiety and bipolar disorders across all ages, I have utilized methods like exposure therapy, cognitive-behavioral therapy (CBT), and Acceptance and Commitment Therapy (ACT). Despite extensive training, I initially found a gap in approaches tailored for autistic or ADHD clients—a significant, often undiagnosed, subset of my clientele.

After years of working closely with these groups, I developed a specialty in ADHD and, more recently, in addressing unique anxiety manifestations within this population. In my practice, I've noticed that traditional treatment methods often fail to meet the needs of my neurodivergent clients. I’ve dedicated considerable effort to understanding these discrepancies and have drawn insights from specialists like Megan Neff and Keiran Rose. I believe that our current “best practices” can inadvertently harm neurodivergent clients, including those with ADHD, AUDHD, and autism.

Understanding Dread vs. Anxiety in Neurodivergent Individuals

In our therapeutic practice, it’s crucial to distinguish between anxiety and dread, as these experiences manifest differently, especially in neurodivergent individuals. Anxiety typically involves apprehension or worry about potential future events that may or may not happen. In contrast, dread is a more intense form of distress associated with the anticipation of known, unavoidable stressors. Neurodivergent people often experience dread stemming from living in a world that expects them to function without adequate accommodations. This misunderstanding can lead therapists to mislabel their dread as anxiety, which not only misdirects treatment but can also feel like gaslighting to the individual. Recognizing and addressing this difference is fundamental in providing effective support and avoiding common therapeutic missteps that can exacerbate their distress.

Here’s what I’ve learned about the distinct ways neurodivergent individuals experience anxiety and dread, and how we, as therapists can better support them:

Critical Considerations for Neurodivergent People:

• Beyond Capacity Social Demands: It is critical to avoid imposing 'normal' social expectations on individuals who may find these demands overwhelming. This can exacerbate their anxiety, encourage masking, and lead to nervous system dysregulation.

• Executive Functioning Overwhelm: We must recognize when anxiety is due to challenges in executive functioning. The "just try harder" approach is not only ineffective but also harmful.

• Sensory Overwhelm: Respecting, rather than challenging, the sensory sensitivities of neurodivergent individuals helps prevent overwhelming them, which can trigger anxiety. Traditional exposure therapy is inappropriate here.

• Routine Disruption: Neurodivergent individuals often depend on predictability. Disruptions to expected routines can induce significant anxiety. Maintaining consistency is key, not forcing them to adapt to disruptions.

Step-by-Step Guide for Therapists: Assessing and Treating Neurodivergent Anxiety

Step 1: Conduct a Comprehensive Assessment

• Objective: Identify the specific type of anxiety or related experiences the client is dealing with.

• Actions: Ask detailed questions to discern if the anxiety relates to dread in these areas: sensory or social overwhelm, routine disruptions, or executive functioning challenges.

Step 2: Develop a Personalized Treatment Plan for Dread-Based Responses

• Objective: Customize a treatment approach that respects the client’s neurodivergence, focusing on dread-based responses.

• Actions: Educate on and plan with appropriate accommodations. Develop coping strategies that align with the client’s comfort levels and values.

Step 3: Monitor and Adapt

• Objective: Regularly assess the treatment’s effectiveness and adapt as necessary.

• Actions: Hold follow-up sessions to adjust the treatment plan based on client feedback, especially regarding sensory accommodations and therapy pacing.

Step 4: Educate and Empower

• Objective: Enhance the client’s understanding of their neurodivergence and provide tools to articulate their experiences.

• Actions: Acknowledge the potential complexity and overlap of issues, promoting a deeper understanding of unique challenges.

This newsletter has been a decade in the making. I struggled with implementing practices that didn't fit with my clients, despite being taught otherwise at conferences.

I want to credit Megan Neff who has recently helped me solidify some of these ideas and emphasize that self-accommodation and self-compassion are key tools to use with clients experiencing these issues.

Thank you for considering these ideas. I hope they prove helpful as you strive to serve clients who aren’t responding to conventional treatments. Please feel free to reach out and connect with me!