Decentering Neuronormativity: A Transactional Analysis Impasse Theory Perspective for Understanding ADHD Masking

Published Title: Decentering Neuronormativity: A Transactional Analysis Impasse Theory Perspective for Understanding ADHD Masking and Authentically Honoring the Da Vinci Archetype Within

Authored by: Cheryl Leong and Romy Graichen

CC BY-NC statement

This is an Accepted Manuscript version of an article published by Routledge/Taylor & Francis in the January 2024 Issue of the Transactional Analysis Journal. https://doi.org/10.1080/03621537.2024.2286581

It is deposited under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/ ), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Author Bios:

Cheryl Leong (CL) is a licensed marriage and family psychotherapist in California and is based in occupied Mewekma Ohlone land (San Francisco) as a private practice owner. Her 2-decade psychotherapy experience spans across both Singapore and San Francisco, and her training background included a Master’s in Counseling Psychology (Jungian-Based Expressive Arts Therapy), Transactional Analysis Practitioner Certification with the North America TA Association, and Relational-Systemic Family therapy. Cheryl can be reached at email: [email protected]

Romy Graichen (RG) has over 2 decades of experience spanning pastoral care, safeguarding and crisis intervention services, and private practice. She is a registered BACP counselor and currently in advanced TA psychotherapy training. As a trauma specialist with a focus on neurodivergence, Romy uses approaches such as somatic trauma therapy, brainspotting, and eye movement desensitization and reprocessing (EMDR) alongside transactional analysis to support clients. Aside from being the core trainer for the Specialist Diploma in Neurodiversity Informed Psychotherapy at The Greenane Centre, Ireland, she is also the safeguarding lead and clinical supervisor at an international counseling organization based in the United Kingdom. Romy can be reached at email: [email protected]

Abstract

Inspired by the Renaissance artist and polymath Leonardo da Vinci as an ADHD (attention deficit hyperactivity disorder ) archetype celebrated for his creativity, brilliance, endless curiosity, and experimentation, this article brings to awareness links between genetic traits and neurodivergence. It seeks to rethink the ADHD diagnosis and proposes a TA-neurodiversity affirming lens for navigating neuronormativity as well as healing from its oppressive structural and systemic processes. In particular, impasses are explored in the context of how neuronormativity impacts relational material and drives adaptive masking patterns, racketeering, and script formation. The authors present the masking-authenticity triangle framework, which provides an intersectional and standpoint epistemological inquiry into the clinical presentation and developmental trajectory of neurodivergent masking.

Introduction

In 1995, I (CL) was diagnosed with attention deficit hyperactivity disorder (ADHD), which at the time was not widely understood in either the therapeutic field or in terms of clinical diagnostic protocols. In our experience, the diagnosis was and still is ridden with stigma and misunderstanding. It has been either discounted as not an “actual” condition, seen as an individual’s character flaw, or been over pathologized as an impairment or deficit. Therapeutic interventions were historically determined from misinformation or inadequate clinical knowledge. In addition, the atmosphere surrounding assessment, diagnosis, and treatment was pessimistic and objectifying. This impacted the way I (CL) received therapy and treatment. I found what I experienced to be negative, and it often caused more harm than good.

After having been diagnosed as dyslexic (in 2003) and autistic (in 2021), I (RG) was diagnosed with ADHD in 2022. At that time, there was more understanding and awareness. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.) (DSM-5) (American Psychiatric Association, 2013) allowed for co-occurring autism and ADHD diagnoses whereas the previous edition of the DSM would have excluded such a dual diagnosis.

Over time, we have witnessed a shift around the ADHD narrative toward neurodiversity and away from pathology. Advocates started to push for a more positive and strength-based celebration of ADHD traits and a compassionate view of its vulnerabilities. This article shares how we approach and work with adult ADHD in our private practices. We propose a multidimensional therapeutic perspective on ADHD: as a diagnosis, as genetic traits having evolutionary benefit to the larger society, as both suppressed and thriving in relational systems, and as an archetype in our collective unconscious. This framework is multidimensional, so client material is often presented in paradoxes and impasses. In other words, there are contradictions in the client’s psyche that need containment in the therapeutic space.

Comas-Díaz and Rivera (2020) described the practice of liberation psychology as an approach adopted by mental health practitioners who “acknowledge the confluence of clients’ internal world with the systemic sociopolitical forces affecting health and well-being” (p. 9). From this liberation psychology lens, systemic oppression such as ableism is intersectional. Baskerville (2022) offered a transactional analysis (TA) framework for observing intersectionality as intrapsychic processes. This article distinguishes itself from an ontological or a phenomenological point of view and is instead expressed from a standpoint epistemological lens by which inquiry is made from a marginalized social position (Borland, 2020). We argue that knowledge from the standpoint of neurodivergent experiences has traditionally been dominated by a clinical lens that is ableist. This article is written from the standpoint of a neurodivergent perspective in relation to an ableist neurodominant one. The quote below best explains liberation psychology and the type of epistemology from which we write:

One of the central claims of most or all standpoint epistemologists is that the experiences of those who are marginalized in various ways within a particular social structure are a clearer window onto facts about that social structure and the power dynamics that characterize it than are the experiences of the privileged. (Lavin, 2023)

From the perspective just cited, both in the therapy room and in wider society, an ADHD client is living in an ableist system that centers on the comfort of neurotypical experiences. Clients also exist with an ethnic identity or a cultural heritage that is racialized in a system of White privilege, a system of orientation that renders privilege to hetero identity, a limited gender binary system, and a classist system that maintains wealth for the privileged few. Our liberation psychology work is one of uncolonizing (Rodriguez, 2021) psychotherapy and considers oppressive conditions that impact mental health. Neuronormativity as an oppressive condition refers to the set of assumptions, norms, and practices that privilege neurotypical thinking and perceive it as the only acceptable or a superior form of cognition. This societal condition stigmatizes attitudes, behaviors, or actions that reflect neurodivergent ways of thinking as deviant or inferior (Catala, 2023). It also involves a set of assumptions that centers neurotypicality as a clinical set of standards and norms.

We hope to introduce the concept of “decentering neuronormativity” (Leong et al., 2021) and shift readers toward “neurodiversity”’ as a clinical value and thus, psychological liberation for the client. This neurodivergent standpoint epistemology decenters and uncolonizes the assumed neuronormative norms by which traditional psychotherapy works. We view societal systems as pathologically oppressive and thus as having feedback loops that maintain pathology. As such, and ethically speaking, it is vital that the therapeutic process is culturally responsive and humble. The aim of applying such a clinical lens is that clients can then navigate oppressive systems in ways that are culturally sound as well as discover ways to permit the Natural Child to be.

Rethinking the Diagnosis

ADHD specialist Dr. Edward Hallowell, in an interview with the Parents League of New York, described the limitations of the term “attention deficit hyperactivity disorder” as a diagnostic name because the potential upsides of it get lost (Parents League of New York, 2021). The term can be too narrowly focused or misleading. It is arguably an inaccurate representation of the experiences of many individuals. ADHD minds often display increased attention to stimuli or activities differently from neurotypical individuals, such as internal thought processes, wandering, daydreaming, or focusing on thoughts related to the subject matter. In both our personal and clinical experience, it is hardly ever an experience of “attention deficit” but more the case that an ADHD mind is paying attention to the things that a neurotypical mind would likely not attend to.

The term “hyperactivity” is also subject to negative connotations and misinterpretations. Historically, hyperactivity has been understood as an increase in motor activity beyond the normative range for a given individual’s age and developmental stage (Werry, 1968). The perception of a norm for motor activity is inherently unjustifiable from a neurodiversity perspective because it represents neurotypical social-relational standards. The dominant lens, used by clinicians to assess and diagnose, limits understanding of what makes an ADHD person physically active in specific contexts. It has also prevented us from differentiating whether such activity is only external or if there is a more profound internal process worth studying. Hyperactivity may also be labeled “impulsive” when it could be composed of a more intricate psychomotor process. Further, it is problematic to limit the interpretation of increased motor activity as a sign of anxiety, trauma, or intentional disruption of neurotypical standards. Such interpretations are often dismissive, incomplete, or inaccurate. Moreover, it has also undoubtedly led to misdiagnosis or overdiagnosis and, ultimately, inadequate or improper treatment. In the service of rethinking the diagnosis, we will now consider the genetic evidence.

The DRD4 Genetic Trait as a “Da Vinci” Archetype

Hartmann (2005) introduced the idea of “The Edison Gene” or 7R variant of the dopamine receptor D4 gene (DRD4), a genetic variant associated with ADHD. This genetic variation results in an increased sensitivity to novelty and impulsivity. Studies have shown that individuals carrying this gene are more likely to demonstrate difficulty focusing and organizing tasks, restlessness, excessive talking, and difficulty following through on instructions. This gene is also linked to higher creativity, curiosity, and risk-taking behavior, which may explain why those who carry it are often successful entrepreneurs and creative thinkers, as Hartmann observed (p.1–23).

Studies and literature have suggested a link between ADHD, creativity, and entrepreneurship. A review by Cho and Jiang (2021) suggested that overall, adults with ADHD are more likely to generate original and innovative ideas when they have the opportunity to compete for rewards. The results of the reviewed studies indicate that creativity in individuals with ADHD goes beyond clinical settings as it may be enhanced by their preference for task motivation, which is deeply rooted in everyday life. Further, a multiple case study of 14 entrepreneurs previously diagnosed with ADHD indicated that impulsivity was a significant driver of entrepreneurship, and hyperfocus was a catalyst for both its positive and negative consequences (Wiklund et al., 2016). Furthermore, several studies (Lynn et al., 2005; Matthews & Butler, 2011) found a form of the dopamine receptor gene (DRD4) to be positively selected 40,000 years ago. It is associated with ADHD symptoms in the general population as well as the novelty-seeking temperament. These studies offer a celebration of ADHD temperament traits. LoPorto (2005) honored ADHD traits by describing them as a “Da Vinci archetype.” LoPorto himself, a successful technology entrepreneur, published the first nonclinician book for the ADHD community. He steered many perspectives to view the diagnosis as the Da Vinci archetype associated with novelty-seeking traits or DRD4 genetic traits. He encouraged the ADHD community to move toward nourishing these and seeing them as unique qualities with evolutionary and profound purpose.

The Da Vinci archetype is an iconic figure in literature, film, and other media forms, embodying creativity, curiosity, and exploration. In 2019, on studying the life of Leonardo Da Vinci, two neuroscientists proposed that the Renaissance legend had ADHD.

… historical documentation supports Leonardo’s difficulties with procrastination and time management as characteristic of ADHD, a condition that might explain aspects of his temperament and the strange form of his dissipative genius. Leonardo’s difficulties were pervasive since childhood, a fundamental characteristic of the condition. There is also unquestionable evidence that Leonardo was constantly on the go, keeping himself occupied with doing something but often jumping from task to task. Like many of those suffering from ADHD, he slept very little and worked continuously night and day by alternating rapid cycles of short naps and waking. (Catani & Mazzarello, 2019, p. 1845)

This article does not suggest that any single genetic factor ultimately determines if an individual’s clinical presentation meets the criteria for an ADHD diagnosis; instead, multiple genetic and environmental factors contribute to this presentation. ADHD is much more complex than a mere deficit of attention or a list of symptoms associated with hyperactivity or cognitive dysfunction. However, this article emphasizes a need for the field of TA psychotherapy and other relevant fields to consider genetic and neurological traits in its continued development of best therapeutic practice.

Holding the Opposites and Mirroring the Psychic Paradox

The implication of such a shift in perspective had an enormous impact on ADHD psychotherapy. It led to other prominent clinical voices, such as Dr. Edward Hallowell, using the alternate term “variable attention stimulus trait” (VAST) as a depathologizing and strength-focused alternative terminology. This term better captures the experience of ADHD neurodivergence. It also acknowledges that the trait can mean both having unique strengths and also adaptation challenges. Hallowell did not deny the possibility of this trait becoming clinically significant for the individual and therefore justifying clinical support, but he proposed a positive and strength-based approach to understanding and working with the trait (Hallowell, 2018).

I (CL) have observed clients move between these two opposing truths in our practice. The ADHD diagnosis can feel like both a struggle and the most magical gift, and these opposing truths can manifest as psychic tension or impasse. As a therapist trained in Jungian expressive arts, holding these opposites allows shadow material to be analyzed and eventually cultivates union with other parts of the psyche. Jungian analysts Woodman & Mellick (2001) wrote the following:

…as Carl Jung believed, if we held tension between the two opposing forces, there would emerge a third way, which would unite and transcend the two. Indeed, he believed that this transcendent force was crucial to individuation… Whatever the third way is, it usually comes as a surprise, because it had not penetrated our defenses until now. A hasty move to resolve tension can abort growth of the new. If we can hold conflict in psychic utero long enough, we can give birth to something new in ourselves. (p. 188)

This quote captures a Jungian-based approach to ADHD therapeutic material. The Da Vinci archetype often enters the therapeutic space with opposing tensions. Both the symptomatic suffering and the profound strengths or positives are present. Holding the opposing tensions and embracing them with the client can be illustrated in Table 1. A client might enter therapy deflated from a lifelong series of relational rejections, incomplete tasks, painful broken promises, and grief-ridden unfinished business, but they might also exhibit a wealth of untapped creativity and a sense of adventure, curiosity, and passion. Metaphorically speaking, as their therapist, I embrace the tension of the opposites just as I would embrace an infant to contain all parts of their being. In this therapeutic container, the relationship with my client deepens in psychological safety. As a parallel process, having been proudly diagnosed myself, my therapeutic presence, in essence, also mirrors the tension of the opposite. In both holding the psychic paradox and mirroring it, I hope the transformative “third” emerges for my clients.

Clinical Vignette

Khan was newly diagnosed with ADHD, and although he felt relieved to have a name for the various issues he had been struggling with all of his life, he also fought it. He had memories of wondering, seeking adventure, and experimentation throughout his life that he treasured. To think of these experiences as “inattentive” or “hyperactive” felt critical and pathologizing. He prided himself on “hacking” conventional ways of being and creativity and yet countless times found himself in difficult relationships where these patterns hurt his partners. For weeks in therapy, we dived into various painted images of a “wandering ghost” and journeyed into embodying the emotional hunger expressed by this ghost. In working on mandalas further, the ghost imagery began to transform into the face of an elephant. Khan shared a sort of peace and warmth he felt by kissing this elephant image. He began seeing the impact of the choices in his relationships and began exploring the idea of compromise in his dating life. The “third” for him was a union between the shadow of his broken relationships and the beauty of his wandering inner Da Vinci.

ADHD Masking

We believe that many of the impasses witnessed in our practice are manifestations of masking. We define ADHD masking as a social-relational adaptation where an individual camouflages their neurodivergence by conforming to dominant neurotypical expectations. Some studies reveal that ADHD masking can also present as secondary co-occurring symptoms and behaviors such as anxiety, depression, curbing stimming, obsessive checking, and/or perfectionism (Kosaka et al., 2018). This is a clinical phenomenon that is currently under researched and inadequately understood. Kosaka et al. (2018) conducted a study that led them to suggest that in cases of “late onset” diagnosis, individuals who present with ADHD symptoms later in life would have likely masked symptoms during childhood but later experienced stressors that reduced social adaptation in adulthood.

Using a Goulding and Goulding (1976) functional analysis perspective of a type 3 impasse, masking could be understood as a client struggling to manage the stuckness between the Natural Child and the Adapted Child. Mellor (1980) offered a developmental and structural understanding of impasses. Both critiquing and expanding on Berne’s and the Gouldings’ theories, in Mellor’s writings impasses are conceptualized as being stuck between two ego states. He also presented a framework for understanding impasses layered across human development. From a structural analysis viewpoint, Mellor believed that impasses can form throughout a person’s development and may overlap between stages of human development.

In looking at impasses from a developmental lens, we acknowledge that historically, child development perspectives in the field of psychology (including TA) have been viewed from a neuronormative lens. So, we seek to prompt a shift toward TA neurodiversity perspectives. ADHD neurodivergence is currently understood as “neurodevelopmental disorders” as opposed to being viewed as normal variants of biodiversity. What may be considered developmentally appropriate milestones have been centered around neuronormative standards. These neurodivergent presentations have been subjected to neuronormative misunderstandings and continue to result in ableist harm. In contrast, a neurodiversity lens would understand that different developmental milestones and trajectories are expected for differently developing brains and nervous systems. For example, terms such as “preverbal” have historically been used to describe development between infancy and toddlerhood. As such, ADHD individuals who have language-processing differences have been pathologized or have been said to have “speech delays” or other disorders. Other examples include motor skills, social skills, cognitive skills, and so on. In other words, neurotypical clinical standards have affected the ways in which family systems, wider cultural parent norms, and structural ableism develop and harm. Masking patterns emerge in an ableist system, and impasses are formed in these contexts.

The following section describes how we have worked with masking impasses in private practice.

Masking as Third-Degree Impasses

Although a current literature review finds inconsistencies in identifying predictors of ADHD diagnosis in infancy, some studies have indicated links between infant temperament and diagnosis in later life (Athanasiadou et al., 2019). In exploring feeding and other early material in my (CL) practice, I have come to understand these impasses as related to relational adaptations as well as the infant’s temperament. During an initial presentation, what may be deemed “emotional dysregulation” or “sensory dysregulation” can often, in addition, have an underlying layer of a third-degree impasse in later sessions.

Figure 1 illustrates how a third-degree impasse might present in therapy. I (CL) use as an example a client, Evan, who expressed much of his psychic energy as stuck in the primal somatic child. We conceptualize C0 as a representation of the early nervous system’s basic needs and P0 as a representation of the early nervous system’s experience of sensory input from the environment. Although the C0 has the basic somatic needs of being, feeling, and hunger, the somatic experience of parental absence is felt in the P0. Before I became Evan’s therapist, he had been in and out of alcohol recovery in-patient programs and was diagnosed with ADHD. The impasse between his C0 and P0 was experienced as chills in his body and a felt sense of disappearing. However, his energy was larger than life when it came to his ideas, interests, and intentions. He would begin each session hungry but unaware of his hunger. Although he intellectually knew he had to eat, he felt unable to do so and would express a feeling of being frozen in time.

With such early material, it is challenging to decipher what may be a relational adaptation versus a genetic temperament emerging, but attuning to what emerges moment by moment and reading my somatic countertransference informs my work. In a body-centered countertransference experience, changes like body temperature, sensations, heart rate, and muscle tension can reveal both as bodily experiences as well as imagery and symbolism. These could be a mirroring of the client’s Somatic Child (C1) experience, a projected Parent ego state, or dissociated/excluded Somatic Child experiences. My work with third-degree impasses includes somatic mindfulness, expressive arts imagery, and relational therapy, that is, using mindfulness techniques to invite the client’s observing ego to notice the somatic material, interpreting and holding archetypal imagery as transformative via the arts, or inviting the client to navigate relational needs collaboratively in the therapeutic space.

Masking as Second-Degree Impasses

Mellor (1980) explained that second-degree impasses develop during the mid-to-late toddlerhood phase. Figure 2 illustrates how a second-degree impasse might present in the therapy space. A client expressed that they had vague memories of feeling exuberance as a toddler while playing with food and spreading it all over the walls. This scene was juxtaposed against an angry parental voice yelling at them for doing that. They then felt shame and sadness. As a client in their 40s, their sense of vitality (which is so often seen with ADHD) came with playfulness or creativity that was paired with shame and a sense of being undeserving of happiness or joy. The client also presented low mood and anxiety symptoms that impacted their work and intimate relationships. For this person, working with masking and second-degree impasses involved an exploration of early scenes, deconfusing the child ego state, and relational work.

Masking as First-Degree Impasses

In practice, it is not uncommon for first-degree masking impasses to involve school-based experiences. For neurodivergent clients, some of their most challenging social experiences have involved difficulty conforming to classroom cultures or social expectations. Figure 3 illustrates how a first-degree impasse might present itself in the therapy space. I (CL) offer as an example a client who presented in therapy as having career choice difficulties and challenges in the workplace. She had earlier memories of struggling to understand teacher instructions in elementary school and feeling dread and boredom constantly in the classroom or while doing homework. The most brutal memories were having to sit still and curbing her drive to jump up and go. Her fears about career choice stemmed from feelings of both inadequacy and fear of dealing with constant dread in the workplace or not meeting deadlines.

Reiterating what we wrote earlier, masking can present in the therapy room in multiple ways. What can appear to be depressive symptoms or anxious behaviors can initially be diagnosed as co-occurring diagnoses or symptoms. What we have witnessed is that often, addressing the masking patterns while permitting the authentic feelings and needs to be expressed in manageable ways ultimately reduces these co-occurring symptoms. A client may mask their time blindness or working memory challenges by anxiously checking and rechecking if their keys are in their bag. We allow clients to acknowledge that these anxious masking patterns were archaic survival conclusions for adaptation while simultaneously and jointly reassessing their present-day effectiveness.

Neurodivergence, Masking, and Life Script

In this final section we will apply TA theory to a framework for understanding ADHD neurodivergence, relational experience, systemic/environmental factors, masking (racketeering), and script formation. As mentioned earlier, child development research and theories were established based on neuronormative children. However, we argue that the development of neurodivergent children differs significantly due to their unique neurological needs as well as the impact of (Cultural) Parent expectations and norms on both child and caregivers’ relational experiences. Additionally, from a liberation psychology framework, the systemic and structural standards designed for the neuromajority impact the developmental psyche. Beyond specific familial cultural norms, larger oppressive standards influence child development and family norms. Having a child that develops differently holds meaning for the family system: For some it can mean intense shame and blame, depending on the cultural and societal norms they live in.

We hope to shed light on the fact that members of the family may be unaware of their own neurodivergent needs. This could impact the way they perceive their ADHD traits and how they navigate those traits with others. The masking we described earlier could thus contribute to the formation of an intergenerational family script, that is, script programming or the “hot potato” episcript (English, 1969). With the heritability of ADHD at approximately 80% (Grimm et al., 2020), it is likely that at least one biological parent and possibly siblings may also have ADHD traits. In the United States, it is estimated that less than 20% of adults with ADHD are currently diagnosed or treated (Ginsberg et al., 2014). This is consistent with our experience of work with families: We have observed that more often than not, immediate related family members remain underdiagnosed with little awareness of neurodivergence.

Systemic factors that impact the family may also include the educational institutions’ inability to meet neurological needs appropriately. The school learning environment usually centers on neuronormative standards. Assessments and school ethos and values transmit powerful messages of how to be and which aspects of the self to hide. For example, after-school “restraint collapse” is common among neurodivergent children as they fall apart at home after white knuckling a busy school day and managing their needs within the complexities of school. Thus, different environments allow or negate the expression of neurological needs.

The neurological needs of neurodivergent children are either met, partially met, or denied by caregivers, wider child-rearing structures, and educational institutions. These relational experiences of attunement and misattunement lead to the development of impasses, invalidating one’s needs, and giving up one’s authentic self in relation to others and concurring script decisions.

English (1971) described racket feelings as “substituted” feelings in environments where authentic feelings were not permitted. Masking often involves a suppression of feelings that are dismissed in the family or wider societal system. Recent research has termed this substitute feeling “meta-emotion.” Gottman and Gottman (2018) described a meta-emotion structure as “an organized set of feelings and concepts about emotion, and this idea includes the idea of an emotion philosophy” (p. 181). In their research, two patterns were revealed in parental responses to children’s expression of emotion. The first was “attuned” and the second was “dismissing.” Where emotions were attuned to, there were “emotion-accepting” relationship patterns. Those who grew up with emotion-dismissive patterns had one or more emotions minimized, and there was a “substituting” of those emotions for a different one. English (1976) also introduced the concept of “racketeering” as “transactions in the service of a racket” (p. 78) and as an adapted means of receiving strokes. Masking for strokes is an adapted way to get one’s neurological and relational needs met for survival.

The Masking-Authenticity Triangle

Although our article so far has focused on ADHD, this section proposes a framework we call the “masking-authenticity triangle.” We find it useful for understanding therapeutic presentations of the wider neurodivergent population. Figure 4 illustrates how forms of neurodivergent expression can be affirmed or repressed in systems that create complex patterns of masking. Safe environments allow for neurodivergent needs to exist authentically. We define “authenticity” using the concept proposed by Eric Berne?—?the Natural Child?—?and use this framework to analyze the multiple interpersonal, intrapersonal, and biosocial systems that contribute to masking as a clinical presentation.

Historical therapeutic methods have mistaken masking patterns as “healthy,” thus gearing therapy toward such inauthentic adaptations. An example of this is mistaking a client’s change in behavior from “blurting out” thoughts to silence as positive change or symptom reduction when, in reality, the client may be merely masking by shaming themselves into a depressive quiet state. If authenticity is valued, facilitating therapeutic environments to permit true expression of neurodivergence and masking would be ideal.

We want to emphasize that “systemic and structural oppression” are factors that contribute to masking patterns and that social structures can be “structurally violent” (Galtung, 1969). By this we mean that factors such as ableism can have a direct or an indirect violent impact of tissue damage and are possibly determinants of illnesses (Farmer et al., 2006), including mental health symptoms and suicidality. These have effects on the longevity and mental well-being of our clients (Anchuri et al., 2021). As a parent of children with sensory differences, I (RG) have battled the entrenched structural violence within school settings. My child expressed the extreme stress she experiences when wearing tights to her school counselor. He suggested a form of gradual exposure therapy so she could eventually wear tights for a whole day. Her sensory pain was dismissed, thus leading to an impasse of both wanting to be compliant and tolerating physical pain. This scenario arguably equates to a neurotypical child having to tolerate an agonizing burning skin sensation just to conform to a school standard.

Figure 4 illustrates via arrows how various factors are interrelated and contribute to how masking patterns develop as racketeering.

Case Illustration

The following case of a composite client illustrates how these factors relate. Xena was understimulated at school (environment) and in a low mood for most of her childhood. Her neurological need was to be well stimulated, and so she survived by expressing this need through rule breaking (ND / Neurodivergent expression) at home (environment) and at school. The rule breaking would involve convincing other students to play pranks on teachers or to defy classroom instructions. The school (environment), although aware of Xena’s neurodivergence (neurological needs), was ill equipped to manage those behaviors and so resorted to imposing on her sanctions such as detentions and a negative point system (relational experience) to control her behaviors rather than supporting her neurological needs. This, in turn, was experienced as shaming for Xena and her family.

Xena was also from an immigrant family of color, and the school staff and counselors did not have the cultural humility or competencies to be aware of both culture-specific needs and intersectional complexities around racialized oppression and neurodivergent stigmatization (environment meets relational experience).

At home, her parents experienced high levels of shame and anxiety because of social pressures to culturally assimilate (factors influencing environment) and so struggled to navigate their child’s ADHD-related needs as well as the stigma. They wrestled to support her in getting her ADHD stimulation needs met. The family lived with and battled with multiple issues of oppression, and Xena experienced a good deal of family shame and anxiety (environment).

The pressures and shaming from both family and school led to the development of a first-degree impasse (see Figure 3) (impasse development). Xena eventually switched from acting out to express the boredom to anxiously controlling her need to be well stimulated with socially acceptable behaviors such as sitting quietly, biting her inner cheeks, chewing her fingernails, and pinching her thighs in school. Additionally, she worked out that she could get positive conditional strokes for being helpful to teachers by offering to assist, which in turn provided more stimulation (masking). She found a way to get her need for recognition met without negative consequences for her or her family. Boredom is not a permitted feeling, whereas pleasing authority and feeling anxious is more socially acceptable. Anxious pleasing also allowed Xena to receive the strokes she needed to keep surviving the environment.

Intrapsychically, Xena experienced an impasse between the need to be well stimulated and regulated in her C2 (Child ego state) and Parental messages from school and home to “Please others” in her P2 (Parent). Her survival conclusions were: her needs are not OK, and she can make her family/teachers happy by pleasing them (script / survival conclusion).

Conclusion

The institution of psychotherapy has historically made attempts to “cure” neurodivergences, and thus, treatment goals have involved pushing clients to appear more neurotypical. I (CL) was told by a well-intentioned therapist that my “excessive” daydreaming was a schizoidal adaptation to traumatic intimacy. And so, in social relationship situations it would be best to snap a rubber band around my wrist to wake up and affirm my “inner child” that it was OK to be present. This would then solve the problem of my “inattentiveness.” I interpreted this as having to become more neurotypical. It took years to heal from the shame of having the diagnosis of ADHD, and therapy, unfortunately, was a significant contributor to this. “Cure,” from our point of view, has historically been measured in terms of increasing neuronormative behaviors in a neurodivergent client. The example just cited has led to harm, suppression, and erasure of neurodivergent expression.

Cultural Parent messages stem from neuronormative standards that then inform case formulation and treatment norms. By transforming the Cultural Parent, we are seeking, instead, to affirm and celebrate ADHD divergence as expressions of neurodiversity. By holding and mirroring the opposite tensions and unmasking the Da Vinci archetype, we hope to liberate our clients’ uncultivated potential and support them in identifying neuronormativity as an introjected Cultural Parent that fuels masking impasses. This supports autonomy and freedom.

We have offered our masking-authenticity triangle to elucidate how neurodivergent clients can embrace their authentic selves within a therapeutic environment that is informed and affirming. This framework also illustrates how uninformed or invalidating environments can lead to repeated misattuned relational experiences. The suppression of the authentic self follows, with clients needing to mask.

Through both our lived and clinical experience, we have come to understand the importance of shifting away from the status quo and dismantling the ableism that continues to plague historical therapeutic practices. Our ultimate desire is for therapy to be liberating and supportive to neurodivergent clients and supervisees. We hope that this article will stimulate further discourse and discussion around best therapeutic practices for working with ADHD and contribute to the ongoing expansion of applied neurodiversity perspectives.

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