By Chelle Doetsch
Editor’s note: With 15–20 percent of the world’s population exhibiting some aspect of neurodivergence, it’s likely that many of the clients currently on your appointment schedule fall in this group. Understanding the challenges these clients face is important for the success of the work you do together. Chelle Doetsch’s article, “How to Better Serve Your Neurodivergent Clients,” is featured in the May/June issue of Massage & Bodywork magazine. This blog accompanies that article.
What is Neurodivergence?
Neurodivergence is not a medical term; instead, it’s an umbrella term used to describe people using words other than “normal” and “abnormal.” According to the Cleveland Clinic, the term neurodivergence refers to “people whose brain differences affect how their brain works. That means they have different strengths and challenges from people whose brains don’t have those differences.”1 That’s important because there’s no single definition of “normal” with respect to how the human brain works. Someone who isn’t neurodivergent is called neurotypical. Let’s take a look at some of the communication challenges affecting neurodivergent clients.
Communicating with Neurodivergent Clients
Many neurodivergent people have not only sensory processing differences but also language processing and communication differences.
The most common communication differences are oversharing, undersharing, speaking anecdotally, being blunt/direct, having a high need for specificity, difficulty describing emotions (alexithymia) or physical sensations, and situational mutism. Executive dysfunction and a need for structure also have a communication component.
There’s no one communication profile for a neurodivergent person, even if they have the same diagnoses or conditions. That’s because each person has a different handful of traits and different lived experiences.
Your older neurotypical clients and those with visual processing issues may prefer to communicate by phone. Those with auditory processing disorders and younger neurotypical clients may prefer text messages or email. Being open to multiple lines of communication is immeasurably helpful.
Oversharing and Undersharing
Those with greater communication difficulties will almost certainly have a history of being misunderstood. As a result, they will often share as many details as possible, especially when it’s important that they’re understood. However, if they’ve been repeatedly accused of or chastised for oversharing, they may err in the other direction and not share enough.
If we want to effectively relieve our clients’ pain and improve their range of motion, we need to know as much information as possible. Asking as many questions as we need is key. A lot of neurotypical clients tend to undershare, so we’re pretty practiced in drawing out additional information. But did you know that questions can also be the solution to oversharing?
I can’t count the number of times a client has given a lot of detail, then said, “Sorry, that’s probably TMI.” My response is always, “It’s better to have too much information than not enough.” With the rare exception, some part of their TMI would give me a clue that helped me more fully understand what needed to be addressed in their body. It’s also led me to ask different follow-up questions that caused me to adjust my initial treatment plan into a more effective one. Those TMI nuggets help me help my clients, even when other providers haven’t been able to provide relief.
Your neurotypical clients with a history of abuse, neglect, or trauma may also have these communication issues.
Anecdotal, Direct, and Specific Communication
It’s common for neurodivergent people to communicate anecdotally and be accused of re-centering a conversation on themselves. This can get them in trouble in conventional social interactions. However, it shouldn’t be a problem in your treatment room since the conversation should already be centered on them.
They are also often accused of being too blunt or direct. One of the reasons they tend to be more direct is simple: they say what they mean and mean what they say. It can be downright confusing for a neurodivergent person when someone says one thing but means another. With their varied communication issues, it can be difficult to be understood or get their needs met unless they’re blunt or direct.
Note: Being blunt or direct is not an excuse for being rude or insulting. If someone is insulting you, you do not have to tolerate it. You may, however, need to reevaluate or redefine what you mean by rude or insulting in contrast to merely being direct. If they are simply stating a fact, they’re not being rude.
In the same vein, many neurodivergent people also have a need for specificity. They do not do well with vague directions or expectations. “Undressed to your comfort level” is confusing for some neurotypicals, and it’s downright perplexing to many neurodivergents. I’m sure you don’t want to tell someone they have to take their clothes off, but there’s a workaround. You can say something like, “Today, since we’ll be addressing an issue with your low back, it would be very helpful if you took your jeans off, but you can leave your underwear on, unless you’d be more comfortable without it. Either way, that area will remain covered during the massage.”
Note: Many neurodivergent people, for a variety of reasons, hate the feeling of undergarments (seriously, they’re a sensory nightmare for many), and may not be wearing any underwear. They can also be keen rule followers. By acknowledging that it’s OK to take off their undergarments, they’ll be less self-conscious and won’t feel like they’re doing something wrong by not wearing underwear on the massage table. They’ll also feel accepted and be more likely to rebook.
Along with a need for specificity, many neurodivergent people have bottom-up thinking, which means they need to know as much as possible about their choices before making a decision. Too many choices will result in decision fatigue and often result in no decision at all. It can make choosing a service, appointment time, or even a music playlist impossible. If a client seems to have decision paralysis, try giving them a small subset of choices and be clear that you are only offering choices that you would be happy for them to choose, so there’s no wrong answer.
Many neurodivergent people experience and describe emotions, pain, and bodily sensations differently than neurotypical clients. They may describe a physical sensation as a whoosh, bubbly, swampy, dense, or any number of unconventional descriptors. Sometimes it can be easy to tell what their unusual descriptor is describing; other times it’ll be a complete mystery to you unless you ask some more questions. “Tell me more about the whoosh,” “Where does it start and end?,” and “Do you feel it with specific positions or movements?” are great follow-up questions to help you understand.
They may also need time to process how their body feels during the massage. While this is partly an interoceptive issue, it becomes a communication issue when common questions like “How are you feeling?” or “Is this pressure OK?” are asked. These questions can sometimes be difficult for a neurodivergent person to answer. If they’re having trouble answering a request for feedback mid-session, you can try asking if what you’re doing feels beneficial, relevant, harmful, or neutral. You can also ask if any sensations elicited by your work feel familiar. If so, keep doing what you’re doing and check back in a little bit.
When a client tells me they don’t know if they feel better after a session, I affirm them by telling them, “That’s fine. Sometimes it takes a while for all the changes to settle in enough for us to feel them.” Note: To many of us neurodivergent people, this is exactly how it feels sometimes . . . as though the changes slowly settle into our bodies. I am affirming the physical feelings they are likely having. This is a very important part of building trust.
Communication is the Answer
Contrary to popular opinion, executive dysfunction is not just an ADHD problem; it’s also present in many neurodivergent conditions. Many neurotypical people, especially those who are highly stressed, also have issues with executive dysfunction. While technically not a communication difference, good communication in the form of appointment reminders is extremely helpful to ensuring people remember their appointments. If you haven’t automated this yet, you should really consider doing so.
While a need for structure is not technically a communication issue, the only accommodation we can give falls under communication, so here it is: offer standing appointments. By the way, your stressed-out neurotypical clients also benefit from having more structure in their life and schedule. Bonus: You’ll have a more consistent schedule and shorten up checkout time.
Cat Got Your Tongue?
I’d be remiss if I didn’t mention the prevalence of situational mutism in neurodivergent people, especially those who are autistic. If they experience mental, emotional, or sensory overload they can become unable to speak. Their mind can be screaming but they can’t make themselves speak no matter how hard they try. The DSM (Diagnostic and Statistical Manual of Mental Disorders) refers to this as “selective mutism,” but those of us who experience it prefer the term situational mutism because we absolutely do not select to be unable to speak. This can and does happen in the massage room, which is one of the reasons that understanding neurodivergence and making accommodations as you’re able is so important.
What You Can Do For These Clients
- Be patient. Let the client give as much detail as they feel necessary; there are often keys in the details that will give you a better understanding of what’s going on in their body and how to address it.
- Be curious. Ask questions. Clarify. Summarize and repeat what you feel is the most relevant info and ask if you’ve missed anything.
- Be specific. Eliminate statements or questions with vague or implied meanings. Say what you mean and mean what you say—in a nice way, of course.
- Keep your service menu simple. Even neurotypical people get overwhelmed when presented with too many choices.
- Offer a small number of booking choices. This can be a win-win, especially if rebooking after a session. Offer the days and times you’d prefer to fill. You get booked the way you’d like, and they don’t get overwhelmed with a huge number of choices.
- Ask for clarification. No matter your client’s neurotype, asking for clarification is always preferable to guessing or ignoring. This is especially helpful when a client uses unconventional descriptions of body sensations or gives you the rather vague complaint of back pain (What part of the back? That’s a lot of real estate with very different muscles to target depending on location.).
- Use appointment reminders. Automate this as much as possible.
- Offer standing appointments.
1. Cleveland Clinic, “Neurodivergent,” last reviewed June 2, 2022, https://my.clevelandclinic.org/health/symptoms/23154-neurodivergent.