Recently, I attended a social gathering with a group of mental health providers. As people were talking, I heard someone make the comment, “Oh, I don’t work with autistic people.” I was not surprised by this comment as I have heard many colleagues say similar things in a number of professional settings over the years. I was also not surprised to observe that most of the other therapists present either offered neutral responses or agreed that they too didn’t work with autistic people.
As an autistic provider and disability rights advocate, I knew I needed to take action. After this incident, I began including an exercise in a training I offer on the intersectionality of neurodevelopmental disabilities and mental health struggles. I have people write down a minority population, then ask them to fill in the following sentence with the group that they chose: “I don’t work with _____ people.”
While most mental health professionals have no objections to someone stating that they don’t work with autistic people, they become quite uncomfortable when they are asked to say, “I don’t work with black people,” “I don’t work gay people,” etc. because this statement suddenly feels like an ethics violation.
Someone excluding clients due to their race, ethnicity, gender, or other minority identity would not be tolerated by colleagues; the decision could even lead to serious professional consequences. If this is the case for other minorities, why does the profession look the other way when many providers routinely exclude clients based on their disabilities? One study by Cantor et al. (2020), for example, found that after calling more than 8000 mental health clinics across the US, only 47% would take a referral for a child with autism.
Systemic Ableism’s Impact on Mental Health Treatment
Over the course of history, neurodevelopmentally disabled people have been othered by society. Up until the last few decades, people with neurodevelopmental disabilities (ND) who had high support needs or could not mask fully were often put in institutions, hidden away from the rest of society. Gen X is the first generation whose disabled members have been allowed to live fully in their communities. Because of this, mental health care has all but ignored this population. There are few evidence-based mental health treatment modalities for autistic people or people with intellectual disabilities because researchers have only recently begun to study the topic in depth. There is also little instruction in mental health training programs about ND.
It’s no wonder that so many therapists feel unequipped to treat this community.
Competency as an Ethical Principle
There is another reason why no one objected when that colleague stated that they don’t work with autistic people. This reason has to do with competency. The NASW Code of Ethics contains the following ethical principle, “Social workers practice within their areas of competence and develop and enhance their professional expertise.” If our mental health training programs are not ensuring that professionals are instructed on how to treat autistic and intellectually disabled clients with co-occurring mental health struggles, then it makes sense that they would feel that they were not competent to do so. If the therapist does not feel competent, they would avoid treating the client in order to avoid an ethical violation.
The Ethical Dilemma
The problem with using competence to dismiss the responsibility of treating a minority population that tends to struggle with mental health at significantly higher rates than the general population is that it becomes a social justice concern that violates other ethical principles. Again, using The NASW Code of Ethics, this becomes a violation of the following ethical principles:
- Service: “Social workers’ primary goal is to help people in need and to address social problems.”
- Social Justice: “Social workers challenge social injustice.”
- Dignity and Worth of the Person: “Social workers respect the inherent dignity and worth of the person.”
This ethical dilemma isn’t exclusive to social workers.The American Counseling Association Code of Ethics values professional competence, but also has principles that create a dilemma.
- Client Welfare: “Primary Responsibility: The primary responsibility of counselors is to respect the dignity and promote the welfare of clients.”
- Roles and Relationships at Individual, Group, Institutional, and Societal Levels: “Advocacy when appropriate: Counselors advocate at individual, group, institutional, and societal levels to address potential barriers and obstacles that inhibit access and/or the growth and development of clients.”
- Nondiscrimination: “Counselors do not condone or engage in discrimination against prospective or current clients, students, employees, supervisees, or research participants based on age, culture, disability, ethnicity, race, religion/spirituality, gender, gender identity, sexual orientation, marital/partnership status, language preference, socioeconomic status, immigration status, or any basis proscribed by law.”
In my intersectionality training, after completing the exercise described above, I ask the following discussion question: “When is it responsible practice to refer a neurodivergent person to a specialist and when is it ableism?”
For those reading this post, I pose the same question.
Competence is important and research has shown that ND clients do better when therapy is modified to meet their diverse learning needs. However, because they system does so little to train therapists to feel competent, it has created a mental health crisis. For example, autistic people are 9 times more likely to die by suicide than the general population. As a profession, we can no longer sit back and do nothing to meet the needs of ND clients because of a lack of competence. It’s time to learn about the mental health needs of ND people and address the competing principles in this ethical dilemma.
