CBT and Neurodivergence

Cognitive Behavioural Therapy (CBT) has long been considered a “gold standard” in psychological treatment, praised for its structured, evidence‑based approach to anxiety, depression, and stress. Yet within the neurodiversity movement, CBT has been the subject of growing critique. Autistic advocates and neurodivergent thinkers point out that traditional CBT often assumes neurotypical patterns of thought and behaviour, framing differences as “distortions” to be corrected. This can feel invalidating, as it risks pathologising identity rather than supporting wellbeing.

At the same time, many clinicians and clients argue that CBT can be highly effective when adapted. By focusing less on “thinking errors” and more on practical, step‑by‑step strategies, CBT can provide clarity and predictability—qualities that often resonate with neurodivergent individuals. The tension lies in whether therapy is used to normalise or to empower.

Some autistic advocates caution against ruling out entire therapeutic models like CBT. In the UK, where CBT is often the primary therapy offered through the NHS, dismissing it wholesale risks denying autistic people access to services altogether. Without adaptation, autistic clients may find CBT invalidating; without access, they may be left without support.

Voices from Autistic Advocates

Autistic advocates emphasise that therapy should never aim to “fix” autistic traits, but rather to support wellbeing. As the National Autistic Society explains: “Neurodiversity is a way of saying everyone’s brain is different. A neurodiversity approach views autism and other forms of neurodivergence as natural variations in people, not deficits to be corrected.”

Autistic UK has warned against excluding CBT altogether: “If CBT is the only therapy offered through NHS pathways, rejecting it outright risks leaving autistic people with no access to support. The problem is not CBT itself, but the failure to adapt it to autistic needs.”

NeuroTribe UK, a neurodivergent‑affirming therapy service, adds: “We believe in creating a world where every one of us is seen, respected and valued for who we are, not just who others want us to be.”

Rather than describing autistic people as having “deficits in theory of mind,” advocates suggest reframing this as differences in perspective‑taking. This acknowledges that both neurodivergent and neurotypical people may struggle to understand each other’s viewpoints. As one autistic therapist noted: “It’s not about lacking empathy, it’s about different ways of experiencing and expressing it.”

By shifting language from deficit to difference, therapy becomes more collaborative and affirming, recognising mutual challenges in communication rather than placing the burden solely on autistic clients.

Dr Vanessa Ruspoli, a Chartered Counselling Psychologist who qualified in 2005, has been working at this intersection for two decades. She began her career as Psychology Manager at the Hoffman Foundation for Autism, later worked at Priory Hospital and Cygnet Hospital, and now runs a private practice. With expertise in CBT, EMDR, and systemic approaches, she has developed a practice that is both evidence‑based and neurodiversity‑affirming. In this interview, she reflects on how CBT can be adapted for autistic clients, what neurodiversity‑affirming care looks like in practice, and the challenges of distinguishing identity from co‑occurring conditions.

Q1. Can CBT be helpful for neurodivergent clients? Please explain your response.

Dr Ruspoli: Yes, it absolutely can. When CBT is adapted thoughtfully, it can become a supportive and empowering tool for neurodivergent clients. Rather than trying to “correct” differences, I focus on developing strategies that respect individual identity and lived experiences. For example, with autistic clients, I adapt around perspective‑taking, recognising that communication styles and ways of processing the world are valid in themselves. I use clear, literal language and practical alternatives so clients aren’t expected to pick up on nuance or implied meaning. This makes CBT more accessible, and importantly, it honours the client’s way of being while offering concrete tools to manage challenges.

Q2. How do you adapt CBT for neurodivergent clients?

Dr Ruspoli: I avoid framing things in terms of “thinking errors” and instead concentrate on the presenting problem. For example, I worked with a client who was struggling to accept that she could not have a romantic relationship with one of her co-workers. By sticking to very literal reasons for why that boundary exists, and then exploring step‑by‑step alternatives for moving forward, she was able to find practical solutions. That kind of structured, concrete process is really important. Adaptation means meeting clients where they are, not asking them to think or behave in ways that feel unnatural to them.

Q3. How do you define neurodiversity‑affirming care, and how does that show up in your work?

Dr Ruspoli: I think of it in the same way I do with any of my clients: individually. I look at what the client is presenting with, what their difficulties are, and how I can support them in managing and functioning within the world. It’s down to them what they want to work on, and it’s not based on a model of what I think is best, but on what they think. Neurodiversity‑affirming care means respecting autonomy, validating difference, and building therapy around the client’s priorities rather than imposing “normalising” goals.

Q4. What is your approach to distinguishing between divergent ways of being and symptoms of co‑occurring mental health or health conditions?

Dr Ruspoli: I see the person as an individual and think carefully about each element—what’s likely a neurodivergent trait, what might be other factors, and what they want to work on. Many of my clients are referred through psychiatrists, so there is often already a diagnosis in place. My role is to integrate that information while still focusing on the client’s lived experience, making sure identity is not confused with illness. It’s about separating difference from distress, and ensuring that support addresses suffering without undermining identity.

Q5. What’s your experience of working with neurodivergent clients?

Dr Ruspoli: It’s been very rewarding. Neurodivergent clients often challenge traditional therapy frameworks, which pushes me to adapt and grow as a clinician. When CBT is tailored and more literal, more structured, and focused on practical steps, it can be empowering. Clients gain tools to manage distress and navigate challenges, while their identity is respected and affirmed.

Practical Adaptations Checklist

For clinicians and clients, here are key adaptations that make CBT more neurodiversity‑affirming:

• Literal framing: Use clear, concrete language rather than abstract or metaphorical reasoning.

• Perspective‑taking reframed: Talk about differences in perspective, not deficits in empathy or “theory of mind.”

• Client‑led goals: Therapy should prioritise what the client wants to work on, not what society expects them to change.

• Practical strategies: Step‑by‑step processes, visual aids, and structured problem‑solving make CBT more accessible.

• Sensory awareness: Adapt session length, environment, and pacing to respect sensory needs.

• Validation first: Affirm identity before addressing distress, separating difference from suffering.

• Rather than describing autistic people as having “deficits in theory of mind,” advocates suggest reframing this as differences in perspective‑taking. This acknowledges that both neurodivergent and neurotypical people may struggle to understand each other’s viewpoints. As one autistic therapist noted: “It’s not about lacking empathy, it’s about different ways of experiencing and expressing it.”

• By shifting language from deficit to difference, therapy becomes more collaborative and affirming, recognising mutual challenges in communication rather than placing the burden solely on autistic clients.

Dr Ruspoli’s reflections highlight the tension at the heart of CBT and neurodiversity: whether therapy is used to normalise or to empower. Some autistic advocates remind us that ruling out CBT entirely risks denying services, while unadapted CBT risks invalidating identity.

For more information on Dr Ruspoli:

www.dr-ruspoli.com