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AutismBC Talks

Neuroaffirming mental healthcare for autistic clients

December 5th, 2023

AutismBC

For Autistic Adults, Caregivers

Meet Rae Morris, a passionate researcher and advocate for neuroaffirming care.

Beyond the academic realm, Rae is a mental health therapist who collaboratively engages with clients to address challenges spanning mental health, self-esteem, neurodivergence, well-being, and relationships. Her expertise extends to working with neurodivergent adults, many of whom have suspected or confirmed autism and/or ADHD diagnoses.

As a dynamic PhD candidate, Rae immerses herself in groundbreaking research and shares her wealth of knowledge by teaching clinical practice courses to Master of Social Work students.  

Join us as Rae Morris offers her thoughts on offering neuroaffirming mental health care for autistic clients.  

An image of a person holding a brain and looking inside. Generated by artificial intelligence using Canva.
An image of a person holding a brain and looking inside. Generated by artificial intelligence using Canva.

This transcript was edited for length and clarity after Rae Morris spoke for an AutismBC Talks event on Nov. 29, 2023.

Q: How do I support meltdowns, be it my own or my child’s?

A: By the time you or someone has reached a meltdown point, your system is fully and completely overwhelmed. Those of you who have experienced this know it full well. Supporting someone through that experience is about being present, being calm, and supporting safety.

At that point, that person is not able to turn on their cognitive brain and answer questions or be talked through this. In that moment, it’s offering that gentle support and then time for recovery when possibly a debrief or discussion can happen.

When it comes to supporting meltdowns, the best support is actually pre-emptive. With the clients we work with who do experience meltdowns, we spend a huge amount of time being like, “What are all the tiny and infinite little factors and contributors that get you closer to potentially experiencing a meltdown or potentially further from experiencing a meltdown?”

We’ll look at different areas of their life, like sensory environments, different environments, different people. We look at different thought processes and demands on your life in really close detail.

Having that information can allow you to have insight and support yourself, but then you can build yourself a really individualized toolbox of supports and things you can use to meet your needs.

If your workplace environment has a lot of different sounds going on … recognizing, “Oh, if I use noise-canceling headphones at work or advocate for a quieter space at work, it will make it more likely I can avoid complete overwhelm.

Also, this kind of insight can help in telling care providers, partners, family members, or other loved ones what you might need in those moments. For examples, if you notice I stop talking and go non-verbal, don’t ask me questions in those moments.

This takes a lot of time, exploration, and looking at a lot of different things, but in my experience, this type of work is really long-lasting and sustainable. The amount of meltdowns my clients experience before versus after this work is hugely different, and so this can be really impactful.

Although it’s more common for neurodivergent folks to experience meltdowns, it’s not an inherent association that being neurodivergent means you’re someone who has meltdowns. It’s more about being overwhelmed by neurotypical demands, by sensory input, and then reaching this overwhelm where meltdowns happen.

In my dissertation project, as Liv mentioned, I asked autistic adults and mental health providers about their experiences at the intersection of autism and mental health, and also their experiences with support and services. People talked about the themes at the intersection of being autistic and mental health … and four key themes came up: Masking and camouflaging, social isolation and loneliness, change and uncertainty, and sensory differences. These are four key areas you can look at for yourself or someone you care for, to say, “What’s going on in these areas?” and “Are there any spaces where you’re feeling you have to do a lot of masking or camouflaging? Are there spaces where you don’t feel you need to do that?”

Social isolation and loneliness — are there places where you feel connected to others, connected to the community? People you feel connected with online, in person? What does that look like?

It’s about reinforcing in all four of those areas, including sensory differences and processing as well.

When I’m working with someone who’s moving, it’s a lot of change at once. It’s a huge transition. Even in a brand new place, it’s brand new smells. New neighbours around, new trees, a new pollen environment around you. The walls look different. The neurotypical expectation of moving is about moving your stuff and setting up. It’s not good enough recognition of all the tiny sensory changes that happen when you move.

In those moments, we ask clients, “What are things that you can reinforce?” Your brain is struggling with all this change and uncertainty, so let’s talk about what you know. If your cat is coming with you, your cat’s not changing, you still have your cat, so you can pet your cat and spend more time with your cat during the move. I have a favourite TV show I’ve seen 1,000 times. I’m going to watch that show every night before the move day and after the move day … so just feeding your brain what it needs during that time of uncertainty, which is predictability and routine. Eat the same foods.

Q: I used to have more capacity to “push through” than I do now, and I’m feeling super burnt out. What should I do and how can I ask for support when I feel too burnt out to do so?

A: Like meltdowns, at that point of burnout, asking for resources or asking for support — maybe somebody says, “Get a counsellor,” but searching for that counsellor requires a ton of energy. The traditional things people think of when they think of self-care take a lot of energy.

When I talk about making a toolbox for yourself, if you have a toolbox already made before you reach the point of burnout, you can figure out, what are those tools for when I’m struggling, going towards burnout or meltdown? What are the ones that are fast and easy and right there that you can do? I know someone who splashes water on their face and it sort of resets their sensory system.

Burnout is bigger than meltdown. It’s much bigger and much longer, and it’s an impactful experience for people.

There’s an autistic researcher named Dora Raymaker out of Oregon State who is one of my research articles, and … Dora published a study recently on this, looking at experiences of burnout among autistic adults. She asked participants, “What are the things that help you in restoring yourself and coming back to a baseline or a place of thriving for yourself when you’re experiencing burnout?”

The autistic participants who answered this study talked about access, and social support, so having community supports or peer supports … attending to autistic needs, spending time unmasking, and going to spaces where they feel accepted in person or online spaces. The second theme was leaning into autistic strengths, so this is another one people find to be helpful during burnout. If you have something that is a special interest, then yes, go spend the weekend learning about that or deep diving into that. That can be an effective form of self-care that can kind of be underplayed by the neurotypical understanding of self-care.

Another theme is having formal support, which includes mental health support or formal breaks from work or school, asking for extra time and the ability to socially withdraw.

Of course, a counsellor can support you through a burnout process, but sometimes, if you don’t already have that connection with the counsellor, starting that process while you’re already experiencing burnout can take a huge amount of energy. So having those support systems in place when you’re not experiencing burnout as a pre-emptive measure can be helpful.

The participants talked about reducing load, so trying to take away activities as you can, setting boundaries, and asking for help in places where you can or are able to.

There’s self-advocacy and health, so focusing on a healthy lifestyle. Many of the participants talked about getting a formal diagnosis, which of course is not the most accessible thing. It’s expensive and waitlists are ridiculously long in British Columbia, but actually, several studies have shown that … confirming a diagnosis can be helpful for people.

I think that the world is shifting to a place of more acceptance of self-diagnosis particularly in the autistic community, so there’s that too: Talking to other autistic people to say, “What do you think and have you experienced this?” Getting that validation from your experiences and reinforcing a diagnosis that you believe fits you can be the same type of validation as they would have been getting with a formal diagnosis.

Self-knowledge is what I was talking about before, having that really deep insight into the factors that contribute to me feeling well or thriving. What are all the factors that are challenging for me or that can contribute to burnout for me? And then using that knowledge to keep yourself feeling well. It’s balancing when I need to push through something and help myself get through it, like a move … versus is the system pushing too hard and now is the time to advocate for no, this shouldn’t be happening. For example, I should be able to use noise-cancelling headphones at my workplace and it’s unacceptable that you’re not allowing me to do that because then I can’t focus and I’m not feeling well at the end of the day.

Another theme was engaging with the autistic community. This is another theme that is becoming common in research. It’s something we’re thinking about a lot in our practice too because of the social isolation and loneliness theme that is intersecting with the mental health of autistic people.

Sometimes I talk to people and if they’re hesitant or not ready to engage with real-life people, then go and read books written by autistic or neurodiverse authors. Go listen to podcasts so that you’re connected but you don’t have to use the energy to engage yourself until you’re ready to do so. Or go on Discord or Reddit server and read what other people talk about, which can be validating.

I have another study that I read recently about youth and being heard and understood about their mental health. Youth are another population that is marginalized for their expertise of themselves. A lot of providers consider that youth don’t know what they’re talking about when it comes to their mental health and the adults and the experts. I read this study that talked about epistemic justice, or the centering of the lived experience and expertise of youth. I think this applies to neurodivergent folks as well who sometimes get treated like this. One of the things that was analyzed by the researchers looking at these youth stories is that when youth have the language to articulate their experiences in a way that mental health providers understand … they have more power in the things they say.

This can help in those conversations with healthcare providers or mental health providers. The more you know about yourself, the more you’ve heard other people articulate these experiences, and the more language you’re going to have to explain what’s going on in a way a provider can understand.

This is not the same with therapists and counselors and so forth. They have a responsibility to also change their language to match you so it’s more collaborative and you don’t have to articulate your experiences in such a way. The power dynamic of seeking a diagnosis or medication or something like that is not the same as it is with a therapist. If you find you’re doing that with a counsellor… then I would encourage you to consider if that counsellor is the right fit.

An autistic child expressing distress. Generated using artificial intelligence on Canva.
An autistic child expressing distress. Generated using artificial intelligence on Canva.
Q: How do I support the mental health of my autistic child or youth? How do we know and balance when to offer more support, when to offer leeway, when to hold them accountable, and when to hold others accountable — for example, schools?

A: This is one of the most common questions that parents come to me with. Many parents had these exact concerns: How to balance these things? Usually, it’s a long conversation that I have with the parents. It’s a very challenging question to respond to in a general sense because it depends so much on who you are as a parent, who your child is, and what your family culture is like. What is around your family culture? What are the systems like?

Mental health is impacted by so many things, and support needs to come from so many places. There are external and internal influences on the mental health of your child or youth, so it can be challenging for any of us to understand and navigate the balance between these things.

For someone like a child or youth, this can be especially challenging. For somebody who’s neurodivergent, there are these neurotypical expectations of what mental health looks like, which can create even more doubt in that internal knowledge of what’s impacting their mental health.

Many autistic or neurodivergent people get encouraged overtly or subtly throughout their lives to push through. If you’re in a workplace where there’s lots of sensory input going on, and at the end of the day you’re drained and trying to explain that to somebody, and their experience of that sensory environment is very different … then the message for you is you maybe just need to try harder. You may just need to push through. It’s not that loud in here. Or if you show up late to class every day in school, you get in trouble, and the belief around showing up to class is if you cared to be here, you’d organize your time and figure out your stuff. But if you’re walking into the hallway in the transition between classes and it’s already a transition for your brain to go from being in math class to now being in the hallway and then going to gym class, that’s a lot for your brain to process.

Has anybody, as an adult, been to a school? It is such a sensory nightmare during the break between classes. Not only is this a transition between two spaces, but there are all these people everywhere, all these sounds and sights, and — especially in high school — lots of different smells. There are lockers slamming and bells going off, and some people will just freeze. If your body and brain are in complete sensory overwhelm, you’re going to go into fight or flight mode, so you won’t do anything until the hallway starts to clear out and then you’re late for class. So you’re late for class because your sensory and cognitive systems got overwhelmed, and then the teacher says if you cared or tried harder, you’d be here.

How to support your child and youth is to explore. Explore all of this. Explore what you’re observing. You know, “I noticed every day this week, you told me you were too overwhelmed to help with dishes … What’s that about? What’s contributing to you being overwhelmed?” The child may or may not have answers for you right away, but even just asking somebody those questions prompts, in their head, to start thinking about it.

Then there’s role modeling yourself. I have a four-year-old child and we had a party in the summer, and I noticed my child was getting overwhelmed at one point by all the people and sights and sounds going on. So I took my child and brought them to his room and turned the light off with them, turned on a little lamp, and said, “Woah. Sometimes when I’m in a space and there are a lot of people around, I get excited and my brain feels loud and busy, and I realize sometimes I need to come take a break somewhere where it’s nice and quiet and dark. Do you ever feel like that? It’s nice to be sitting here in the quiet. I already feel my brain getting quieter. Do you feel that too?” And we kind of talked that through and then checked in a few minutes later, and said, “Okay, I think I’m ready to go back out. What do you think? Are you ready?”

For my child, I didn’t ask them, “What’s going on for you? Are you feeling overwhelmed?” They’re four years old, but already modelling that language and experience for myself might help them think about these things in environments where their brain is feeling loud.

Having those discussions with your child and opening up the conversation to exploring those experiences is supporting your child or youth to build that toolbox.

So if you’re feeling too overwhelmed to do the dishes, what might help you get there? Is it something about the dishes themselves? Is it the sense of the gloves the slippery soap on your hands or the dirt? Are the dishes the issue, or are you feeling too tired? I notice you’re less likely to do the dishes on days when you have soccer after school. It’s about being inquisitive and recognizing that, in many places, the rest of the world is telling your child to just keep pushing through.

Sometimes, them asking for a break from you and telling you they’re overwhelmed is representative of, at school, them pushing through all the time: “I’m camouflaging and trying to meet all these expectations, and by the time I get home and I get to be myself, I can say, ‘Parent, I can’t do it.’” It’s exploring that with them.

Q: For both youth and adults, what kinds of neuroaffirming therapies are out there?

A: There are some types of therapies that neurodivergent folks tend to align with or feel are a better fit than others. For example, acceptance commitment therapy, sometimes dialectical behavioural therapy (DBT), sometimes not, and sometimes somatic focus therapy. But it’s interesting because I think the thing about being neurodiversity-affirming as a therapist or counsellor sometimes is about pushing back against the idea of purist model-based practice.

They have a lot of empirical support behind, these therapy models, but they are designed for all brains and the research behind them wasn’t conducted on all different types of brains. Neurodiversity-affirming therapy is more about the clinician than it is about the particular model itself.

A neuroaffirming counsellor would see the expertise that you bring as well, so instead of you both grounding in this particular model that’s empirically supported, it could be using components of a model or using a model but also considering your lived expertise as the client or person experiencing this and including that in the therapeutic work.

Many clinicians know that the research overwhelmingly out there on successful outcomes of therapy says the most important factor … is therapeutic rapport. That means the relationship between you and a therapist. If that space feels like a relatively safe space to talk about and process things, to be heard, understood, and validated, the likelihood of successful outcomes is much higher than it would be if that space feels less safe if you feel less heard, less understood, but you’re grounding it in an empirically strong model.

I think, unfortunately, what happens for a lot of autistic and neurodivergent folk is you become so used to being misunderstood, so used to being misinterpreted, that when you start working with a counsellor or therapist and they don’t understand you or they misinterpret you, it feels like the norm. So you don’t question if this is the right fit as much as somebody else might who has had those experiences of feeling validated and understood.

I encourage people to do consultations with counsellors, therapists, or other providers. I understand why some counsellors don’t do consultations. It takes a lot of time away from people on your waitlist, so I understand why it doesn’t happen, but I think it’s particularly important for neurodivergent people.

That feeling of, okay, I think this therapist is going to get it. I think they hear me and will be able to hear me. They have a lot of knowledge about the systemic barriers that neurodiverse people face … and the common experiences of neurodivergent people. These are the kinds of things that are the most important. In a consultation, you can often get a sense of that pretty quickly — I would say usually within 15 minutes — if you know how to pay attention to that. If you have spent your whole life being misunderstood, being decentered, being told the way you do things isn’t the right way, it’s really hard to get a sense of that feeling.

Q: Where and how can I access mental health supports that are autism-informed or neuroaffirming?

A: I think it’s less about credentials when it comes to this because [autism-informed training] hasn’t caught up with the realities of autistic people’s experiences. A lot of the autism training that is out there is not inclusive of autistic voices. It was not designed by autistic people. It’s not led by autistic people, so be critical when you look at that piece.

I think that the best place right now where there are screen lists of autism or neurodiversity-affirming therapists is within the autistic community. Discord or Reddit spaces, organizations or groups that are autistic-led, they will sometimes have these lists and tell each other, “These are the therapists we’ve worked with and they’re great.” As far as I know, that’s the best place right now to do that.

Sometimes therapists will tell you that they’re autistic or neurodivergent and that can be a helpful screen as well because they will have a different understanding of your experience than somebody who is not.

Q: How do I tell healthcare professionals that I’m neurodivergent?

A: First, I think it’s important to note that there are actual risks and benefits to telling a healthcare professional that you’re neurodivergent, so an exploration of this for yourself is a very personal decision. There are real risks. I did a study a couple of years ago and I looked at all of the research to date on healthcare providers’ experiences when working with autistic patients, and overwhelmingly, the providers talked about feeling out of scope. So when they knew that a patient or client was neurodivergent, they felt no longer as confident or capable of offering support as they were before. I personally have had this experience of telling a healthcare professional that I was neurodivergent and them saying, “Oh, I don’t think I can offer you support anymore.” I was like, “You’ve known me for four or five months. What changed? This one thing I told you that I’ve known about my brain this whole time?”

So there are real risks, but there are also real benefits, right? If you can tell your healthcare professionals this and they give you resources or recommendations. If you’d like to request accommodations at work, healthcare professionals have a lot of power in the letters that they write to schools or employers about this. First, I think it’s exploring that decision, because once something is said, it can’t be unsaid. Ask yourself, what is it I want them to know and why do I want them to know it? What’s the benefit to me of telling this healthcare professional?

When it comes to healthcare professionals, there’s power in the collateral. What I mean by that is that you can say all these other people are thinking this too. If you have a therapist who is willing and agreeable, they can write a letter to say, “I also think this might be true. Here are the things I’ve seen or noticed,” or if you want accommodation at work or school, so they can say “These are the reasons why I know these accommodations will be helpful.”

How you say it depends on what your goals are for them having that information. I’m sorry I don’t have a more specific answer for that.

A client talks across from a therapist, who is taking notes. Generated by artificial intelligence using Canva.
A client talks across from a therapist, who is taking notes. Generated by artificial intelligence using Canva.
Q: What can I expect from therapy? How do I balance getting my needs met in therapy while also being a thoughtful and good client?

A: I have also met many clients who have had this same question. Either they overtly asked me this question or it became apparent that they were thinking about this a lot in our sessions: How to be a good client, how to be the right client, and focusing a lot on who they are in that space.

I think this is another representation of a common experience of being told you need to be different. If you’re spending your whole life with people having these neurotypical expectations of you, with people telling you that you don’t do things quite right without telling you how or why that is, you’re just not quite right in this space — of course, that’s going to be one of the outcomes. When you go to a therapist, you’ll be like, “Okay, I want to make sure that I do this right. What does it mean to be a client? How am I supposed to be acting or behaving?”

Good counsellors can pay attention to this. I think if you have this question, it’s a very good question to ask your counsellors. A lot of the time we are assuming clients aren’t thinking about this, but they’re using that space as they should: To talk about themselves and using us as a support system. If a client says to me directly, “I don’t think I’m being a very good client,” I’ve been so grateful and appreciative of them saying that because sometimes from a therapist’s headspace you don’t even think about that as an option.

It’s having that conversation, navigating that balance, and hopefully collaborating, getting to a place where you’re thinking less and less about how you’re showing up and more about what you’re saying and how you’re being heard in that space.

The balance of getting your needs met and being a thoughtful or good client can be slow and should be a collaborative process between you and your therapists, so ideally you are focusing on yourselves. They have the skills to set boundaries when they need to. If there’s something that’s not okay or has crossed a boundary, they have the skills to say that. If they’re not saying that, you don’t need to worry.

Q: What books do you recommend for supporting autistic people’s mental health?

A: I think the best book I have heard of and the one that is most highly recommended by clients is Unmasking Autism by Devon Price. I think that everybody should read this book.

Of the books that specifically talk about mental health or therapy, I would say the best one I’ve come across is the neurodivergent-friendly workbook of DBT skills.

Q: In what ways can a counsellor or psychologist offer help for children with selective mutism and their families?

A: There are counsellors out there who specialize in selective mutism, so it might be good to start there. I also know BC Children’s Hospital has some specialists in this as well, so depending on where you’re at in the system or what you’ve accessed already, you can search for selective mutism in children. Some people specialize in this.

Q: From your point of view, what kinds of barriers do autistic job seekers face every day?

A: I would say, of course, the biggest barrier is the neurotypical expectation and the balance of personal well-being and deliverables and productivity in the workplace. There is a very good book about employment called Workplace Neurodiversity Rising by Lyric Riviera. I recommend everyone read it as well. It talks about common experiences. It talks about assessment tools. It speaks to workplaces and employers about how to be more affirming, and how to assess the workplace as well. To answer that question much bigger is to say go have a look at that book. It’s a very well-written and practical book.

Q: Are attachment and social differences a reason why employers might not hire autistic workers?

A: I don’t know if this would be one of the reasons why businesses wouldn’t hire autistic workers, but I would say it could be part of the stigma in place for employers. Just like with a healthcare provider, the disclosure of diagnosis in the workplace is also a huge topic that is deserving of a lot of personal thought and reflection and decision-making, because there are actual risks to disclosure of diagnoses in the workplace.

Q: Do you have anything to say about the disclosure of neurodivergence for healthcare professionals?

A: I have so much to say about this. This was a very long experience for me and it took a lot of thinking and reflection. There are a lot of benefits and downsides to disclosure as a professional. One reason I came to disclose in my role as a therapist was asking, “How can I tell my clients that the way their brain works is the way their brain works and to accept that and recognize their strengths and needs, and then not tell people myself?” Ultimately, that was the reason I decided to do it.

I think another challenge that’s coming up now is it’s a little bit of a marketing thing now for counsellors and therapists to say they’re neurodivergent as a marketing tool. Maybe they are, maybe they aren’t, but that caused me to hesitate quite a bit. I didn’t want it to be used as a way to gain power or be more heard or respected. It’s tricky and very personal.

People sitting in groups while communicating on their smart devices. Generated with artificial intelligence using Canva.
People sit in groups while communicating on their smart devices. Generated with artificial intelligence using Canva.
Q: I’ve been doing a lot of research in the States and overseas, and they’re using more and more peer specialists with lived experience. Is there anywhere in BC that they’re doing that, or anywhere in Canada … for autistic families and people with autism?

A: Yes. Some organizations in BC are doing this and offering this. I expect it’s going to become more and more common over time.

Q: What advice do you have for an adult who may be struggling to process a diagnosis later in life?

A: My general advice is just to go slow. You have time to process this.

One thing that commonly comes up for the people I work alongside is the adjustment to understanding relationships — prior understanding of what friendships were or partnerships and how that grounded into your identity and understanding of yourself as a neurodivergent person. You’re becoming more yourself and having relationships around you shifts and changes from that. I think that’s one of the hardest things, harder for many people than processing the actual label. I suggest finding those people who get you, hear you, and make you feel understood and leaning on them.

Q: How can I be proactive with my autistic daughter as she transitions into a full-day Kindergarten program?

A: One thing to ground yourself in is your expertise as a parent. You know your child well. As parents, we know them maybe better than we realize. I suggest paying attention to any changes you observe in your child — anything that’s different, how they are behaving after school.

When it comes to the little ones, it’s a lot about behaviour. A lot of mental health, wellbeing, and emotional stuff shows up as behaviour, so in a way, it’s a good thing because it’s a bit louder than adolescents, where it can be this internal experience. Pay attention to those things in your child and try to find, within the school, if you can, an ally or somebody who you feel gets your child.

You know who I find to be hugely amazing in the public schools is EAs, or educational assistants. If there’s an EA in your child’s classroom … develop a relationship with them so they can tell you what’s going on with your child in the classroom and you can tell them what’s going on with them after.

Are you an autistic person who’s in a mental health crisis or an ally hoping to provide more mental health support? Check out this blog to learn more.

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