Photo credit BigStockPhoto ChinKS
by Dr. Danna Bodenheimer, LCSW, DSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way and On Clinical Social Work: Meditations and Truths From the Field
A client comes into the room and immediately begins scanning.
The window. The clock. The chair. The hum of the air conditioner. The distance between their body and mine. The light overhead. The sound from the hallway. The question I have just asked, which may be simple to me but lands in their body as enormous.
They sit, but not comfortably. Their eyes move around the room. Their hands search for something to do. They begin to answer, then stop. They speak quickly, then go quiet. They may laugh at a moment that does not seem funny, or look away just when the conversation becomes more emotionally charged.
From the outside, this might look like anxiety, avoidance, guardedness, resistance, or dysregulation.
But another possibility lives underneath the clinical language: their body may be accurately reading the room.
What looks like dysregulation is often a perfectly logical nervous system response to environments that were never designed for neurodivergent bodies and minds.
The Therapy Room Is Not Neutral
Therapists often think of the therapy room as a container. A safe space. A quiet space. A place set apart from the demands of ordinary life. But for many neurodivergent clients, the room is not automatically safe just because we intend it to be.
The room is sensory information.
It has lighting. Sound. Smell. Temperature. Texture. Proximity. Time. Eye contact expectations. Seating arrangements. A clock. A door. A waiting room. A script for how the hour begins and ends.
It also has power.
One person owns the space. One person asks most of the questions. One person documents the story afterward. One person decides, often silently, what counts as relevant.
For therapists, this structure may feel ordinary, because we were trained inside it. For many neurodivergent clients, it may feel painfully familiar: another room where someone with authority is trying to assess, interpret, or correct them.
This is why we have to stop treating the environment as secondary to the work. The environment is part of the work.
“Dysregulation” May Be Information
When a neurodivergent client becomes overwhelmed in session, we often ask: What is happening inside this person?
That is not a bad question. But it is incomplete.
We also need to ask: What is happening around this person?
Is the light too bright? Is the room too warm? Is there a humming sound no one else is noticing? Is the chair uncomfortable? Is the therapist sitting too close? Is the question too broad? Is the client trying to translate a sensory experience into emotional language because they think that is what therapy requires?
Is the client actually unsafe, or have they been placed in a context that requires too much translation?
A nervous system response is not automatically a symptom. Sometimes it is a form of accuracy. Sometimes the body is telling the truth before the client has words for it.
The Problem With “Tell Me More”
Therapists love open-ended questions.
- Tell me more about that.
- How did that feel?
- What comes up when you think about it?
For some clients, these questions are spacious. For others, they are overwhelming. For many neurodivergent clients, a broad question can feel less like an invitation and more like a test with a hidden correct answer.
- What exactly am I supposed to tell you?
- How much detail is too much?
- Do you want the literal answer or the emotionally meaningful one?
- Am I supposed to know what I feel?
- Are you asking because you are curious, or because you already think you know what this means?
When we do not make the rules of the interaction explicit, many neurodivergent clients will spend enormous energy trying to infer them. That energy is then misread as anxiety, guardedness, tangentiality, or resistance.
But the client may simply be trying to survive the social architecture of the room.
The Client May Not Be Avoiding the Feeling
Traditional therapy often assumes that emotional depth lives underneath the surface content. A client talks about logistics, facts, interests, timelines, systems, or sensory details, and the therapist wonders what feeling is being avoided.
But not every client organizes experience through emotional language first.
For some neurodivergent clients, experience may be stored as sensation, pattern, music, color, image, pressure, movement, sequence, or fact. A client may not be “intellectualizing” when they give a detailed account of what happened. They may be offering the most accurate form of the story they have.
A client who says, “It feels yellow,” may not be failing to identify an emotion. They may be communicating precisely.
A client who brings in a playlist, a spreadsheet, a map, a special interest, or a long contextual explanation may not be avoiding the “real material.” That may be the real material.
The clinical task is not always to translate the client back into the therapist’s preferred language. Sometimes the task is to widen what counts as therapeutic communication.
When the Frame Forces Masking
Many neurodivergent clients have spent years learning how to appear acceptable in rooms designed by other people.
- They know how to sit still enough.
- They know how to make enough eye contact.
- They know how to laugh at the expected moments.
- They know how to organize their story into a beginning, middle, and end, even when that is not how the experience lives inside them.
- They know how to become a “good patient.”
This can make therapy look successful from the outside. The client is articulate. Cooperative. Reflective. Engaged.
But internally, they may be masking.
They may be suppressing movement, editing language, hiding confusion, ignoring sensory distress, and trying to produce the kind of insight the therapist seems to value.
That is not healing. That is performance. And if the therapy room rewards that performance, we have recreated the same adaptive burden the client already carries everywhere else.
Sensory-Friendly Therapy Is Ethical Therapy
A neuroaffirming frame asks us to take responsibility for the room.
Not perfectly. Not obsessively. Not with the fantasy that we can design a space that works for every body.
But directly.
We can ask about lighting. We can ask about sound. We can ask about smells, textures, seating, temperature, movement, waiting rooms, and time. We can offer fidgets and stim tools without making them feel childish or clinical. We can let clients know they are allowed to stand, pace, sit on the floor, wrap themselves in a blanket, look away, close their eyes, or speak while moving.
We can ask whether the client wants a clock facing them. We can ask whether a 10-minute warning is helpful or stressful. We can stop pretending time is not present while secretly controlling it.
These are not cosmetic accommodations. They are clinical interventions.
They communicate: your body is not an inconvenience here. Your access needs are not a disruption of the work. Your way of inhabiting space matters.
Questions Can Be Harm Reduction
For many neurodivergent clients, being questioned by someone with power has not always gone well.
Questions may have been used to expose them, evaluate them, diagnose them, discipline them, or prove that they were not trying hard enough. So in therapy, how we ask matters.
We can say:
- I know being asked a lot of questions by someone in authority may not have always felt safe. We can go slowly.
- Broad questions may or may not work for your brain. Would you rather I ask something more specific?
- You do not have to answer just because I asked.
- If a question does not make sense, you can tell me that.
- We can pause, skip, or come back.
This is not over-accommodation. It is not fragility. It is harm reduction.
It shifts therapy from extraction to collaboration.
The Room Can Become Reparative
If the room can be a stressor, it can also become part of the repair.
A client who has always been told to sit still discovers they can pace while talking. A client who has always been punished for directness discovers they can say, “That question does not work for my brain.” A client who has always been interpreted through suspicion discovers they can say, “No, that is not what I meant,” and the therapist will believe them. A client who has spent a lifetime masking discovers that the room does not require a performance of neurotypical ease.
These are not small things.
They are moments where the nervous system learns something new about relationship.
Not every room will demand translation. Not every authority figure will punish difference. Not every misunderstanding has to become a rupture.
Rethinking the “Symptom”
The more we understand neurodivergent experience, the more carefully we have to use the word symptom.
- A shutdown may be protection.
- A tangent may be connection.
- A special interest may be regulation.
- A lack of eye contact may be concentration.
- A flat tone may be communication without performance.
- A question may be an attempt to locate the rules.
- A refusal may be self-trust.
- A body in motion may be a body trying to stay present.
This does not mean distress is not real. It does not mean neurodivergent clients do not need support. It means we have to stop locating the problem exclusively inside the person.
Sometimes the suffering is not produced by the nervous system itself.
Sometimes the suffering is produced by the mismatch between the nervous system and the room.
A More Honest Clinical Question
Instead of asking, “How do I get this client regulated?” we might ask:
- What is this environment asking of them?
- What sensory, relational, or communication demands are embedded in this room?
- Whose comfort is the frame organized around?
- What would make this space less performative and more inhabitable?
- What is the client’s body telling me about the conditions I have created?
These questions do not make therapy less clinical. They make it more accurate.
Because neuroaffirming care is not simply about being nicer to neurodivergent clients. It is about rethinking what we have been trained to see.
It asks us to consider that what looks like dysregulation may be adaptation. What looks like resistance may be self-protection. What looks like avoidance may be a refusal to translate oneself into a language that has never fit.
And what looks like a symptom may actually be a nervous system telling the truth about the room.
Dr. Danna Bodenheimer, Founder and Director of the Walnut Psychotherapy Center, has worked in the field of mental health for more than 15 years. Her expertise is most centered around working with the LGBTQ+ population and neurodivergent population. She takes different, cutting edge approaches to thinking about and treating individual and organizational trauma. She has also long studied the impacts of dual marginalization on the psyches of individuals in treatment and in the workplace.
Dr. Bodenheimer received her bachelor’s and master’s degrees from Smith College, her post-baccalaureate degree from Columbia University, and her Doctor of Social Work from the University of Pennsylvania. She has taught at Temple University, Rutgers University, Bryn Mawr College, and Penn. She can easily discuss complex issues of life along the gender spectrum, neurodivergence, racial dynamics in the workplace and interpersonally, and the lifelong impact that trauma has on overall human functionality. She has also authored two books on how to practice in the field of psychotherapy and has mentored hundreds of developing clinicians as they have grown their own practices.
Dr. Bodenheimer has recently developed an expertise around neuro-affirming care derived from multiple avenues of study and clinical work. She is working on a book that affirms that self-diagnosis process and will serve as a guide and journal for those exploring their own neurotypes.