I want to share some thoughts and perspectives around working with Autistic/ADHD folk, specific to concepts of felt safety and of threat. [This is really lengthy so CW: long read - go to the toilet, then make sure you have a snack and drink handy, and strap yourself in]. I'm sharing these in response to themes I have noticed in ruminations by other psychologists lately expressing anxiety that therapy is not working, strategies aren't working, and of not getting anywhere with clients. The following ideas are likely not new at all for some readers, but may be helpful to others hence wanting to share. These are my thoughts/concepts/frameworks informed by a training background in developmental psychology and by using Bronfenbrenner's systems model as an ongoing assessment/formulation tool. I also draw on trauma-informed care, Collaborative & Proactive Solutions (Dr. Ross Greene), and understanding the adaptive functions that demand avoidance serves for clients. These ideas have also been informed over time by working with clients, in that I only work with Autistic, ADHD and multiply-neurodivergent folk. Lastly but not at all in the least, these ideas are informed by lived experience.
First is the concept of 'felt safety' which for Autistic people, is linked with interoception (the awareness and detection of internal physical sensations such as those that demarcate how we know what emotions we are experiencing). Non-Autistic folks (and neurodivergent folks depending on individual circumstances and life-course trajectories) experience 'felt safety' in their environments either unconsciously, or with minimal conscious effort, or with low levels of support. As a very simple example, a non-Autistic person may feel anxious starting a new job but with self-talk, relaxation/mindfulness strategies, maybe some therapy sessions, and the awareness that within a few weeks they will have made peer connections and settled in; they may likely feel okay pretty quickly.
Neurodivergent folks may not experience felt safety at the same pace or with the same ease. This can in part be due to constant sensory and social pressures from birth which may be incongruent with their neurobiology, creating an underlying elevated arousal baseline. When experiencing a high baseline of emotional/physiological arousal, this can feel unsafe and can be difficult to make sense of re: detecting/interpreting the sensations and what they mean. Difficulty with felt safety can also be due to broad uncertainty re: the demands and expectations of situations and people (again due to neurobiological differences in detecting and understanding sensory and social information). This can make felt safety difficult as there may not be the same level of automaticity in working out whether a situation/person is safe or not, that a neurotypical person may experience. [Caveat - this is not true for all Autistic people. Some are exceptional at the 'vibe check' and can tell very quickly when a person and/or situation is unsafe]. My point is that the experience of felt safety may not happen as fast or as unconsciously for Autistic people compared to non-Autistic people. Overall: Differences with interoceptive awareness means it can be difficult to be aware of and interpret bodily cues, whether 'positive' or 'negative'. This means things can feel unsafe within one's body, within a situation, and around a person/people, without the conscious awareness of or language to conceptualise and then communicate 'I do not feel safe right now'. When working with Autistic folks particularly, keep this in mind! It may take a long time before autonomically, automatically and unconsciously, their body experiences felt safety in your space and in your company. Even if your client is seeming fine, keep in mind that there is the potential for the process of not feeling safe to be happening. Resist the frustration and cognitive temptation of 'this isn't working', 'they're not making progress', 'I need more strategies'. Sure, you may need to take a different approach, that could be an explanation. But what I also encourage is that when you think or feel these things, you take time to pull back and reflect deeply on whether your client feels safe. What about you or your environment may not be working for them? Do you have a good understanding of their sensory preferences, aversions and needs? Do you have a good understanding of their social and communication needs? When things fail to launch or if they stall, these questions become more important and you may need to direct yourself to learn more about your client. You may also need to pull back and keep your presence, environment and sessions low pressure and low demand for as long as it takes. I understand that as practitioners we feel anxiety around progress towards goals and families getting value for money, but we also need to consider harm vs. benefit. A dysregulated, unsafe nervous system will not benefit from psychology sessions and that is your justification for putting the brakes on. Threat detection and its relation to the concept of valence/appraisal frameworks in psychology also needs consideration. The factors outlined above can mean that an individual may have a lower threshold for interpreting something as a threat (or may more saliently interpret and respond to something as a threat). This makes complete sense when understanding lack of felt safety. When feeling that frustration/stress about progress not being made/strategies not working, we need to consider whether coming to a session and/or seeing us and/or being in the therapy room are threats. Responding to a threat doesn't always mean acting with a fight response, it can also be what we know of as flight, fawn, freeze, flop. Valence is broad and in general terms involves things like whether emotions are felt as positive/negative, good/bad, pleasant/unpleasant, but also whether a person experiences power/no power or moral goodness/violation. I think of these ideas in my mind as 'threat valence' when understanding and supporting Autistic people: The degree to which things are interpreted/reacted to as a threat in the valid context of felt safety; the calibration of an individual's detection of and response to threat; the degree to which a person feels safe vs unsafe. When talking about demands and demand avoidance, I don't necessarily mean Pathological Demand Avoidance/PDA. I am meaning that when a person does not feel safe and when they may have a lower threshold for perceiving threat, this can be a very anxious, stressful position to be in. An adaptive response that makes sense for that individual and their nervous system is therefore to avoid those demands. The software (demand) is not compatible with the hardware (nervous system and neurobiology). Thinking of it this way, sessions can be demands even when low-pressure and fully child led. Coming to the consult room. Being in the space with another person (us). Activities, books, words, questions, statements. Even doing nothing - they're still there, in the room, with us. All of this is embedded within a Double Empathy framework which may impact the degree to which an Autistic/ADHD person's experiences of these experiences (sorry to get meta) are communicated with you nonverbally, verbally, or in absentia. By 'in absentia communication' I mean freeze/flop/fawn responses. If you feel like things are 'going nowhere' but clients seem engaged or attentive, consider if their observable communication is the client fawning or showing learned complicity that they think you want to hear/see. If you are thinking the client is 'quiet' or 'shy', consider whether they are frozen. It's also important to doubly reflect on whether correct attributions about client responses are being made (double empathy again). These ideas are important for assessment and support/therapy but are also important in schools e.g. classroom engagement, 'school can't'. If you are supporting a student who can't go to school (it is not school refusal - it is not a will not, it is a can not), consider their felt safety with their classroom teacher/s, with peers, with support staff, within the classroom and within the playground. Consider threat valence. Work needs to start here. As written earlier, if a nervous system is dysregulated it's hard for much else to happen. If an Autistic student is therapised into complying with school attendance whilst unsafe, over time this places them under chronic stress which impacts on threat valence. Then we see the cascade of mental health complications and distress that underlies referral to psychology for social/emotional/behavioural difficulties. I am sure you are familiar with the profile of Autistic 8-10 year old children being referred for multiple school suspensions, violence toward others at school, early psychosis symptoms, eating disorders, self harm and suicidal ideation, poor academic progress despite cognitive ability and poor self-concept. If you go right back to basics and day dot, did they experience feltsafety in their education settings, from early on? And if we cast more widely across Bronfenbrenner's systems model, where else has the person experienced felt safety in the past and where do they have it now? Other therapists/allied health disciplines, activities, home? Do the systems have a good understanding of the client's sensory preferences, aversions and needs? Do they also have a good understanding of the client's social and communication needs? I don't have specific tools or resources to give you re: what felt safety looks like in a person, how to check/assess it, how to assess threat valence. These are lenses and concepts and this is neurodivergence affirming work across a potential language barrier (double empathy). These ideas and concepts are for keeping in mind to self-assess during your work, and also to weave into supporting clients. They will look and feel different in practice for every individual client. To continue the crude lens analogy, if I lent you a pair of sunglasses they would look different on you than they do on me. What you see through those sunglasses might also look different to what I see. All I can really say concretely is that all of this takes time. A lot more time than you might anticipate or feel comfortable with. Autistic neurobiology endures across the lifespan, we know this. Autistic people endure. Being Autistic, with all I have written above, is to endure. Given all of this, it is completely valid and realistic if things feel slow to you. We’re here all day, so to speak. I hope you find these ideas helpful. Copyright Rebecca Gannon, 2022.