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Working with clients experiencing professional burnout is a familiar issue faced by workplace therapists. ‘Burnout’ is defined as a state of physical and emotional exhaustion, resulting from long-term stress within the workplace. It is commonly associated with extreme fatigue, feelings of hopelessness and overwhelm, and doubting your professional abilities.¹ While it can wreak havoc with a person’s mental fortitude and sense of wellbeing, it is commonly managed by limiting responsibilities, accessing support, getting restorative sleep, and increasing rest to combat stress and fatigue.¹ Taking these steps can lead to improvements in a person’s emotional and mental wellbeing within weeks.

But just imagine that this state of exhaustion persists, lasting for months, even years. What if your exhaustion became so intense and unrelenting that even basic tasks, such as combing your hair or brushing your teeth, were virtually impossible? Washing and eating are difficult, and some days you are confined to bed. No amount of sleep proves sufficient and when you do sleep, you are plagued by nightmares fuelled by unremitting anxiety. What once sparked joy, cannot lift the black smog that has taken over your body and soul. You’re a shell of the person you once were and, what’s worse, the people around you invalidate these feelings, and reprimand you for your inability to do such basic things.Ìý

My experience

I know this firsthand as I experienced neurodivergent burnout in 2015, early in my nursing career while working as a registered nurse on a busy medical ward. While I started bright-eyed and bushy-tailed, and keen to make a difference, it wasn’t long before my mental health started to deteriorate. I lived with a syndrome of exhaustion, resulting from chronic life stress and a mismatch ofexpectations and abilities, without support.² Neurodivergent burnout results in a loss of previously acquired skills – such as reading comprehension, processing verbal communication and decision making – and can last from three months to several years.³ In some cases, the consequences of neurodivergent burnout can be permanent.²

I experienced panic attacks, recurrent nightmares and chronic low mood. My physical health also suffered. Having been diagnosed with fibromyalgia, I’d grown used to the pain but I soon began experiencing debilitating migraines. I found the hospital environment itself overwhelming, seeking refuge from the bright lights, shrieking alarms and constant chatter in the staff room. Seeking support, a counselling psychologist suggested autism to me as a way of explaining both my mental health struggles and my apparent sensory sensitivities. My initial denial gave way to acceptance and as I read of the experiences of other autistic women, I felt validated. Some years later, my physical pain was explained by my diagnosis of Ehlers-Danlos syndrome, aÌý connective tissue disorder that shares links with autism and other types of neurodivergence.Ìý

Experiencing worsening pain and fatigue, I struggled to attend work but rarely took sick leave due to staff shortages. Back then, nurses were required to work mandatory overtime because of the hospital’s low staff retention rate, and lack of nurses entering the profession. It was not uncommon to work four or five 13-hour shifts each week. The career that once provided purpose, meaning and joy, now evoked heartache and dread, and I took a period of professional leave to re-evaluate my career. However much I valued walking side by side with patients, holding their hand, providing comfort during what, for many, were the most challenging and vulnerable times in their lives, I now knew nursing was not a sustainable career for me. And, my psychiatric nursing rounds had ignited a passion in mental ill-health, so when I was offered a place to study psychotherapy at the University of Edinburgh, I seized it.

What is neurodivergence?

The term ‘neurodivergent’ refers to an individual whose brain processes information in a different way than what is considered typical.⁴ This means that the neurodivergent person experiences the world differently from those whose brains process information in a typical way (known as ‘neurotypicals’).^4,5 The term ‘neurodiversity’ represents the idea that people experience and interact with the world around them in many different ways, and that there is no ‘right way’ of thinking, behaving and learning.⁵

The neurodiversity paradigm was first articulated in 1998 by Judy Singer, the social scientist and autism rights activist, who, in her original thesis, articulated the desire autistic people have to be defined as ‘neurologically different’ rather than ‘disabled’. It has since expanded beyond autism to include other conditions, including attention deficit hyperactivity disorder (ADHD), dyslexia and dyspraxia,⁴ and approximately 15% of the UK population is estimated to be neurodivergent.⁴ I use the term ‘neurodivergent’ to refer to individuals with autism and/or ADHD, specifically.Ìý

Trauma and neurodivergence

During my four-year PhD, I studied the intersection between neurodivergence and trauma, and sought to understand how mental health practitioners can better serve this population. Now in private practice as a psychotherapist, I specialise in working with neurodivergent adults and young people, putting the findings from my research into practice. I’ve discovered just how many of the neurodivergent clients I see have been a part of the caring professions; nursing, social work, teaching and mental healthcare, and how many leave their careers following neurodivergent burnout.

Call for research

Dissatisfied by the woeful lack of research into this area, I designed a survey on neurodivergence in the workplace, sharing it on Facebook with community groups for people with autism and ADHD. Participants were required to have received a formal diagnosis of autism or ADHD, to reside in the UK, to be employed or to have previously been employed, and to be over 18 years old.

I surveyed over 380 neurodivergent people, and a staggering 58% reported current or previous employment within a caring profession (defined as any role that involves supporting the physical or mental/emotional wellbeing of others), while 42% reported employment in non-caring roles. Does this surprise you? If so, you’re not alone as it’s often assumed that neurodivergent people, particularly autistic people, prefer analytical and solitary work such as computer programming, software engineering or data analysis, keeping them secluded from the wider world and relegated to quiet offices. I believe these stereotypes are fuelled by two false assumptions: firstly, that neurodivergent people prefer solitude, and secondly, that neurodivergent people lack empathy, and therefore cannot connect with and care for others.

Capacity for empathy

My nursing background tells a very different story, one that is shared by so many of the neurodivergent clients with whom I’ve worked over the years. Contrary to the stereotypes, the neurodivergent can show extraordinary amounts of empathy – so much, in fact, that learning to establish healthy emotional boundaries is often a major aspect of our therapeutic work. While a central characteristic of autism is difficulty in knowing how to read and respond to the emotions of others, the autism specialists, Professor Tony Attwood and Dr Michelle Garnett, share their insights: ‘Clinical experience indicates that there is a hypersensitivity to feeling another person’s negative emotions such as disappointment, anxiety or agitation. Autistic individuals have a remarkable capacity to mirror, or amplify within themselves, how another person feels.’⁶ This suggests that increased empathy might be an essential reason why neurodivergent workers choose caring professions, but it may also be (as was my experience) a contributing factor to subsequent burnout – particularly in those professions where there is a high probability for vicarious trauma.

Therefore, if we suspect that neurodivergent people are more likely to be drawn to caring professions, and given what we know about neurodivergent burnout and its long-term consequences, how can the therapy profession and workplace therapists, in particular, best support our neurodivergent carers?

Understanding risks

A good place to start is by understanding the significant factors that are most likely to place our neurodivergent carers at risk. High levels of empathy, thought to be present in many autistic people, poses a unique risk,⁷ and we know that possessing increased empathy can leave a person feeling significantly drained, particularly when confronted with other people’s suffering. While it’s well recognised that carers face the emotional toll of exposure to traumatic material and witnessing the distress of others, autistic carers can find this is further exacerbated by their ability to feel the emotions of others particularly intensely. The research points to autistic individuals and those with ADHD being at an increased risk of a range of mental health concerns, including depression, anxiety and suicidality,^8,9,10 as well as experiencing traumas such as bullying, sexual and physical abuse.^11,12

In addition, neurodivergent people can experience challenges in identifying and regulating their emotions.^13,14 This has implications for carers exposed to traumatic material because it can be particularly difficult to process the intense feelings associated with their work. It is important that therapists are aware of this because neurodivergent individuals are also at risk of experiencing co-occurring physical health conditions, including chronic pain and fatigue, Ehlers-Danlos syndrome, joint hypermobility, fibromyalgia and gastro-intestinal complaints.¹⁵ These are all conditions which can impact a carer’s ability to care for others, as well as take care of their own wellbeing. Given all of this, it is clear why neurodivergent carers might seek support via their employer’s occupational health advisors, an EAP or in-house counselling service. Drawing on both my personal and clinical experience, I’d like to offer some advice and guidance to workplace therapists who are working therapeutically with neurodivergent carers.

Recommendations for therapists

Rethink accessibility: The counselling space itself needs to be accessible but due to the neurodivergent client’s increased sensitivity to the sensory environment, it is important to consider the overall suitability of the therapy space, as sensory discomfort will often curtail the therapeutic process. Practical, physical adaptations may include avoiding the use of harsh lighting, minimising clutter, limiting background noise, avoiding the use of strong scents or perfumes, paying attention to the textures used within the counselling space to minimise sensory sensitivity distress and unnecessary distractions.¹⁶

Consider your communication: Therapists may need to adapt their communication style to best suit the neurodivergent client, including being flexible about the way in which therapy is delivered.¹⁶ I use other forms of communication, including drawing or painting, with clients who struggle to put their feelings into words. Therapists should aim to keep their language direct to avoid misinterpretation or confusion, and provide written information about the therapeutic process to accommodate auditory processing difficulties.¹⁶

Written recaps: A recap of the session may prove helpful, and I often set aside time at the end of the session to note what we’ve covered within the session to aid the processing of information.

Be trauma-informed: Given the neurodivergent individual’s increased risk of experiencing trauma, it is important that therapists remain cognisant of this in their work with neurodivergent carers. I have yet to meet a neurodivergent client who hasn’t suffered some form of trauma – be it bullying and victimisation, sexual or physical abuse, or other forms of trauma unique to neurodivergent individuals, such as sensory trauma (resulting from adverse sensory experiences)¹⁷ or invalidation trauma (resulting from sustained rejection and societal marginalisation).¹⁸ The experience of burnout itself can be experienced as traumatic, with wide-ranging consequences for the neurodivergent person, further emphasising the need to prevent burnout in the first instance. Adopting a trauma-informed approach means establishing a sense of safety, being transparent about therapy and the therapeutic process to encourage the development of trust, enabling the client’s decision making, adopting a collaborative approach, and validating the client’s unique feelings and experiences.¹⁹ Therapists supporting neurodivergent carers, and supervisees, need to be cognisant of the risk of vicarious trauma, due to increased empathy and the challenges they may face identifying and regulating emotions.Ìý

Model good self-care: Neurodivergent carers often find that over-investing in the wellbeing of others is followed by emotional burnout and exhaustion. Therapists can help to mitigate these tendencies by emphasising the importance of self-care, discussing the necessity for healthy emotional boundaries, assisting with assertive communication (ie. learning to articulate needs and asserting boundaries), as well as providing a safe space for processing the complex emotions associated with their work. Supervisors supporting neurodivergent therapists need to regularly review the therapist’s caseload to ensure it accommodates the therapist’s own emotional capacity. For example, I know neurodivergent therapists who limit themselves to working with one trauma client per day.

Accommodate co-occurring health conditions: Therapists are well placed to assist neurodivergent carers in exploring what accommodations and adaptations they might require in their work, and how to communicate these needs to managers and employers. The Advisory, Conciliation and Arbitration Service () is an excellent resource for therapists looking to increase their knowledge in this area.

Address working practices: Flexible working and compassionate sick leave policies can go a long way in alleviating the challenges associated with chronic mental and physical health conditions experienced by neurodivergent workers, including therapists. We can model how to nurture a person’s wellbeing, as Carly Radford, a neurodivergent therapist and trauma specialist explains:Ìý

‘Planning a schedule that suits my body and brain has made a big difference to my wellbeing. I used to be flexible and bend over backwards, offering sessions at days/times that suited the client because I wanted to be accommodating. But I wasn’t helping myself and it didn’t actually benefit my clients because I am not my best self in the evenings. My brain is switched off and I also often have pain due to my chronic pain condition. I want my clients to have the best of me and I have learnt I am my best self before 5pm. So, I now only offer sessions in the daytime. This has been the best self-care intervention, but it has also made me a better and more wholly present therapist in those sessions.'

Carly’s reflection shows the benefit to clients when therapists prioritise their own wellbeing, and this has implications for other caring professions. I recall working alongside nurses who were noticeably jaded, lacking the compassion and bedside manner we would expect from someone who had dedicated their working life to caring for others. I now wonder how much of their behaviour was influenced by the lack of support in the system, and having worked in a profession for years that is undervalued and poorly resourced. The same could be said for other caring professions including social work, childcare and teaching. It appears that mental and emotional breakdown seems to be accepted as ‘par for the course’ for care professions, and the COVID-19 pandemic seems to have only exacerbated this trend.²⁰

Therapists tasked with supporting our care professionals owe it to our clients and ourselves to be the exception to that rule. Mental healthcare has an opportunity to serve as an example to other care professions – an example of how to care for others without neglecting ourselves. This starts with acknowledging and nurturing our own needs, regardless of our gender, age, ethnicity or neurotype. For this reason, my overriding recommendation for therapists supporting care professionals is to exemplify self-care through their own actions as this is, in my experience, always of benefit to the client.

Closing thoughts

Since the neurodiversity paradigm began to focus on the strengths which are inherent to neurodivergent people, employers have started to recognise the benefits to having a neurodiverse workforce. Despite some progress, an estimated 30-40% of neurodivergent individuals are unemployed, which is eightÌý times the rate of those without a disability.²¹ Interestingly, 27% of the people in my survey reported being currently unemployed, while 37% reported being self-employed, which may reflect the current unsuitability of working environments for neurodivergent workers, as many may choose self-employment as a way of mitigating these challenges. Crucially, 64% of those surveyed who were unemployed stated that a lack of appropriate support and accommodation within the workplace influenced their decision to stop working. Those working in caring professions reported most often facing emotional challenges, a lack of suitable resources and support, and severe stress and burnout.Ìý

While neurodivergent people may possess extraordinary empathy and be naturally drawn to care work, the figures suggest that the needs of our neurodivergent carers are not being met by employers. I believe that the therapy profession has a role to play in raising awareness of the risks of burnout in neurodivergent people, and the ways in which empathy and vicarious trauma might influence this. Too often, individuals don’t even recognise that they are neurodivergent until they are facing burnout and a mental health crisis, which was my experience and that of many clients I work with.

Sometimes, I ponder what I’d say to my younger self, with the knowledge I now have. I think I’d tell her that prioritising her health and wellbeing is not admitting failure. I’d remind her she is not responsible for everyone’s wellbeing or for making other people happy. I’d tell her that her perceived weakness is her strength, and that the depth of emotion she feels is a gift – one to be cherished, cultivated and wielded. Lastly, I’d reassure her that the darkness will lift, that the sun will rise again and that she will achieve purpose, meaning, and, dare I say it, even happiness.

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