“Ethical Camouflage” in Neurodiversity-Affirming Therapy
By Sam Brandsen
Preface
I believe that neurodiversity-affirming care and disability justice are critical to ethical and effective therapy. This article discusses some structural and relational safeguards that may help ensure these practices continue to be implemented with care. Likewise, I believe these safeguards can prevent potentially harmful practices from being unintentionally camouflaged as neurodiversity-affirming care.
Potential Benefits of Flexibility
Several years ago, when I would present on neurodiversity-affirming therapy, I would often note how flexibility can often be a key part of a neurodiversity-affirming approach. For example:
A patient who has previously been subjected to compliance-based therapies might need a more collaborative, non-hierarchical approach in order to feel safe in therapy.
A patient who has felt constantly scrutinised, infantilised, or therapised throughout their life on account of their neurodivergence (and/or other aspects of their identity) may also benefit from a more “human” approach that focuses on the therapy relationship, building trust, and (appropriate) self-disclosure (rather than a more clinical, detached approach where the patient may feel scrutinised again).
A patient who has a very intense interest that is deeply meaningful for them may need the therapist to engage with their interest conversationally to some extent (as a key part of the patient’s life), rather than redirecting from it or deeming it “not clinically relevant.”
More generally, marginalised people may need to know how the therapist views them. As an autistic person, I don’t think I would be comfortable seeing a therapist who viewed autism as something that automatically needed to be cured or who was hesitant to share their views on disability justice.
The list could go on almost indefinitely, but in the interest of not creating an entire essay on just this topic, I’ll end the list here for now!
I still believe this flexibility can be important and even critical for neurodivergent individuals. And while I am by no means an expert, to my understanding it can be similarly important for therapy that is culturally humble or anti-oppressive more generally.
What is “Ethical Camouflage” and Why is it Harmful?
However, while I don’t believe it’s ever possible to go “too far” in being neurodiversity-affirming, accessible, or anti-oppressive, I’ve come to realise that there are serious risks if these goals aren’t paired with adequate self-reflection or guidance.
I consulted with ChatGPT when thinking about how to frame these risks, and the following quote from it stood out to me in that pre-writing discussion:
"[The risks] don't stem from overt misconduct or ignorance, but rather from a kind of ethical camouflage — where a clinician shields their choices behind a well-regarded philosophy, even when the practical or relational consequences have veered into risk or harm."
An example could be the clinician initially using self-disclosure as a therapeutic tool at the patient’s request, but then continuing to increase self-disclosure over time without reflecting on signs of increasing anxiety or confusion in the patient—all while framing the self-disclosure as part of an accessible approach or a desire to be neurodiversity-affirming.
Or a clinician giving a client who uses AAC an extended appointment time with the goal of equitable access, but then continuing to extend the appointment time more and more in a way that leads to confusion. Or a therapist justifying blurred boundaries with their goal of using an attachment-based or relational model.
Often, these types of decisions begin with genuinely good intentions, but without adequate reflection or support, they can still lead to harm.
In addition to the risks that can come with blurred boundaries in general, therapy harm that is camouflaged as a neurodiversity-affirming approach can actually perpetuate ableism. For example, an autistic patient who feels confused or hurt by a blurred boundary in therapy—but is then told that it was an accommodation or done to be accessible—may only experience compounded confusion. For example, they may think:
“This feels confusing or stressful, but it’s supposed to be autism-affirming, so maybe I’m misunderstanding it or not reacting well?”
“If I feel hurt or confused, does it mean that I’m not being grateful enough for the accommodations?”
“Maybe it’s my fault for being autistic and causing these accommodations. If I wasn’t autistic this confusion would have never happened.”
“Do I just have internalised ableism that I’m not realizing? Maybe if I work through my internalised ableism I’ll be able to appreciate this neurodiversity-affirming therapy approach more?”
So how can one tell the difference between truly neurodiversity-affirming therapy versus therapy that may be starting to slide into an unhealthy dynamic (even if unintentionally) under the guise of being neurodiversity-affirming? Unfortunately, I don’t have a magic answer and don’t think there is a one-size-fits-all approach.
I also realise that these situations may not be completely either-or. An approach may be genuinely neurodiversity-affirming in some ways but slightly overly flexible at times; or an approach may be very thoughtful and reflective but still end up harming the patient because there’s an inherent element of risk in even the “best” therapeutic approach.
Checklist: Potential Yellow and Red Flags
I tend to use self-disclosure as the go-to example, but these could certainly be extended to other areas of boundaries (e.g. dual relationships, session time/structure/environment, gift giving or receiving, etc.) as well:
Did the therapist assume that the patient/client would need a certain type of flexibility or accommodation (e.g. “most of my autistic patients like a bit more self-disclosure, so I’ll use more self-disclosure with this patient because they are autistic”) without asking or directly checking with the patient?
Is the therapist crossing a boundary that they would typically never cross, but justifying it in this case primarily or solely because of the patient’s identity? (E.g. “I would typically never be friends with a patient, but I know autistic people often experience social exclusion, so maybe I should make an exception.”)
Even if the patient did indicate at some point that they find the flexibility helpful:
Has the clinician followed up regularly to check in that things are still comfortable for the patient and discussed potential risks with the patient? (If not, this could be a yellow flag.)
Has there been a “snowball effect” where the clinician is gradually making more exceptions or more significant exceptions for the patient over time? Has the flexibility crossed what the patient initially consented to (e.g. light self-disclosure gradually turning into trauma-dumping from the clinician)?
Are there indications the patient may not be able to fully consent? (E.g. while patient feedback and adaptations can be critical for a collaborative approach, there are things patients simply cannot fully consent to in therapy given the power imbalance. As an extreme example, a patient cannot consent to a sexual relationship with their therapist. I would conjecture that it’s also questionable whether a patient can truly consent to significant dual roles with their therapist in general.)
Is the therapist relying on the patient/client to teach them (directly or indirectly) about best practices for an aspect of their identity? For example, if the therapist is relying on their autistic patient to define autism-inclusive therapy, this may result in a sort of feedback loop (even if unintentional) or shift the patient’s focus away from their own healing and towards educating the therapist.
Is the clinician “picking and choosing” which parts of neurodiversity-affirming practices they want to use (even if unintentionally)? For example, if a clinician finds themselves frequently relying on a neurodiversity-affirming framework to justify flexible boundaries but isn’t putting the same amount of effort into creating other accommodations (e.g. adding structure when needed, creating sensory accommodations, etc.), that may be a sign that the balance is off.
Would the clinician struggle to “go back to normal”? Are boundaries being crossed in a way that is difficult to reverse? If a patient were to suddenly express that they are uncomfortable or feel hurt by the approach, would the clinician be able to support them and learn from that feedback, or would the clinician struggle with defensiveness or fear (e.g. if the clinician has become enmeshed with the patient in a way that makes it hard to receive feedback about stepping back or if the clinician has blurred boundaries in a way where they are worried about being reported)?
Is the clinician starting to view the patient as “special” in a way that adds responsibility to the patient? (E.g. a clinician who is starting to idealise a patient as mature or insightful may overlook their vulnerability in therapy.)
Is the clinician overlooking or not utilising external guidance or other practices to support accountability? (E.g. supervision, ongoing learning, identification of potential risks, time for reflection.)
Closing Note
In some cases, it can be valuable for patients to feel that their therapist is open to learning what a neurodiversity-affirming approach means to them. I had a somewhat complicated experience discussing autism with my previous therapist, but her openness to the topic in general was deeply meaningful to me. However, if the therapist is putting pressure on their patient (even if unintentionally) to educate them, that can be harmful. Likewise, if the therapist is not pursuing ongoing learning about the topic outside of their interactions with their patient, that can increase the likelihood of harm.
