University of Southern California Dissertations and Theses

An intersectional approach to addressing the grand challenge to achieve equal opportunity and justice for neurodivergent individuals in mental health care

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An intersectional approach to addressing the grand challenge to achieve equal opportunity and justice for neurodivergent individuals in mental health care

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Content An Intersectional Approach to Addressing the Grand Challenge to Achieve Equal
Opportunity and Justice for Neurodivergent Individuals in Mental Health Care
Emiley Morton
Presented to the
DSW Program, Dr. Ron Manderscheid, 26 June 2023
Suzanne Dworak-Peck School of Social Work
University of Southern California
In Partial Fulfillment of the Requirements for the Degree of
Doctor of Social Work
August 2023
Table of Contents

Dedication…………………………………………………………………………………………1
Acknowledgements……………………………………………………………………………….2
Abstract………………………………………….……………………………………...………...4
Positionality Statement…………………………………………………………………...……....5
Executive Summary………………………………………………………….……………..…….6
Problem of Practice and Literature Review………………………………………………………7
Stakeholder Review……………………………………………………...………………11
Conceptual Framework and Proposed Solution……………………………………………….....14
Project Description ……………………….………………………………………………...……17
Theory of Change ……………………………………………………………………………….20
Solution Landscape……………………………………………………….………………..…….22
Prototype Description…………………………………………….……………………..……….25
Methodology…………………………………………………….……………………………….26
Implementation Plan …………………………………………………….………………………28
Challenges………………………………………………………………………………….……30
Ethical Considerations and Applying Justice Principles …………………………………/…….32
Conclusion…………………………………………………………………………………/……34
References ……………………………………………………………………….…………...….37
Appendices ………………………………………………………………………………………48
Appendix A (Logic Model)………………………………………………………...……48
Appendix B (Prototypes)…………………………………………………………...……49
Appendix C (Financials)…………………………………………………………………50
Appendix D (Design Criteria)………………………………………….……………….52
Appendix E (EPIS Framework Visual)…………………………………………………54
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Dedication

My work is dedicated to every advocate for the neurodivergent and queer communities
who sacrificed to make the world a safer and more loving place, to everyone who has been
alienated because of who they are and kept fighting anyway, to those who couldn’t keep fighting
any longer and were lost, and to everyone who has ever wanted a safe place to be authentically
themself in this world.

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Acknowledgements

This project would not have been possible without the love, support, and encouragement
I received from so many. I have been most generously and faithfully supported by Stephanie
Poe, who sacrificed her time, resources, and energy to make this project a reality. She has
kept me grounded, focused, inspired, and enlightened, and has been the most important part
of my life and my work. My friends Rachel and Riley Jones have been deeply safe accepted
every part of me, and their encouragement and love has allowed me to approach this project
through the lens of my most authentic self.
My treasured classmates Raine Arnt-Crouch, Illene Candreva, Cyndi Hernandez, and
Erin Perry have patiently supported me, provided invaluable feedback, answered my
countless questions, and extended endless encouragement and support. I have benefited
significantly from the mentoring and guidance of peer-support expert Dr. Laysha Ostrow,
who I have come to greatly admire, as well as the other two members of my committee: Dr.
Sara Schwartz and Dr. Ron Manderschied- both professors who immediately understood the
scope of my dream and what this project could become in ways that were unique and
impactful to me.
The support and trust from my colleagues has been invaluable. I would not have had the
time and energy to bring this design to life if my team at ReviveCincy Counseling hadn’t so
faithfully continued on with their mission to provide high-quality mental health care to our
community while I pursued this endeavor. Most specifically, Leanue Bolo, who has been an
incredible leader and business partner during my absence and allowed me to step back as
often as needed. This project was jointly designed and supported by Emilie Cleaver, without
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whom Reclaimed Divergence would have never become the safe haven it is today for
neurodivergent and queer individuals. She inspires me to continue to redesign this project in
sustainable and impactful ways, supports my ideas (no matter how wild they may be), and
always makes sure we have the funding and resources to bring these ideas to life. The entire
team at Reclaimed Divergence has passionately supported this work, corrected me when I got
it wrong, and patiently endured the many changes that have happened in the office as this
design takes shape. Their courage to live authentically and out as their true selves in their
work has inspired and changed me.

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Abstract

Globally, neurodivergent individuals face significant disparities in every area of life.
Neurodivergent individuals with intersectional identities that also face societal disparity (such as
LGBTQIAP+ individuals) are at higher risks for mental health concerns, social isolation,
unemployment, and death by suicide. To address these problems, this project focuses on
developing an employment model for neurodivergent and queer practitioners where they serve
neurodivergent and queer clients, with a foundation of identity-based care as a strategy to
improve mental health outcomes for clients and employment outcomes for practitioners. The
successful implementation of this project improves employment opportunities for neurodivergent
and queer practitioners, while impacting the overall health for neurodivergent and queer clients.
This solution intersects with the grand challenge to achieve equal opportunity and justice, as it
relates to equity for all neurodivergent people, as well as the grand challenge to close the health
gap. Current practice in mental health care does not offer meaningful training for practitioners
working with this intersection, and mental health care environments are often reported to be
unsafe for them. By changing the way that mental health care practitioners address this
population, processes and outcomes can be drastically improved. This project is innovative in
that it is the first of its kind to use identity-based care as a framework to address the problem of
the intersection of neurodivergent and queer health disparities. Neurodivergent practitioners are
trained to work with neurodivergent patients, addressing multiple levels of disparity through a
systemic lens. The further innovation is that the practice model is completely replicable for any
type of healthcare practice, as it addresses primarily methods of creating safe and affirming
environments for any practitioner and patient who face challenges to be served more effectively.
Keywords: neurodiversity, autism, ADHD, behavioral health, gender identity, sexual identity
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Positionality Statement

My identity may influence my perspectives on this work. I am a white, cis-gendered female,
and I am both autistic and queer. As someone with these intersectional identities, my lived
experience informs this work. I implicitly understand and have experienced many of the biases,
misconceptions, and disparities in access that are well-documented for autistic and queer
individuals. However, being both white and cis-gendered, there are limitations in my
understanding of transgender and gender non-conforming perspectives, as well as the
experiences of autistic people of color. The privilege I hold as a white, cis-gendered individual
places me at a personal distance from the discussions I have prepared regarding the
intersectionality of race and transgenderism in this work, due to my lived experience benefiting
from the white supremacist ideologies that inform so much of society. As such, individuals who
hold these other identities may take a different perspective. Additionally, I am a part of the 15%
of autistic people that have been able to remain consistently employed and have had the privilege
of creating an environment to work in that is safe for me and conducive to my needs, along with
being supported consistently by loved ones when work becomes a struggle. As such, my personal
perspective on employment difficulties faced by autistic individuals is minimal. The autism
spectrum is vast, and my work is influenced more specifically by my perspective as an individual
who is highly verbal and high masking, meaning that I have the privilege to be able to
temporarily attenuate many of my autistic features in areas where it is unsafe to be myself. To
address these gaps in my personal knowledge and experience, I have carefully worked with
individuals who share aspects of these identities or privileges, in order to address my potential
biases or gaps in knowledge.
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Executive Summary

Neurodivergent people have disparate access to affirming mental health care, and have
poorer mental health outcomes as a result. The high rates of intersectionality between
neurodivergent identities and LGBTQIAP+ identities represents additional disparities in access
to all areas of society that uphold white supremacist ideologies and ableism. “Neurodivergent”
refers to any neurotype that differs from the societal standard, such as autism, ADHD, and OCD.
LGBT+ identities refers to those individuals who identity in the queer spectrum with either their
sexual or gender identity. In social work, there are many Grand Challenges that the field seeks to
solve (Grand Challenges, 2022). The Grand Challenge to Achieve Equal Opportunity and Justice
seeks to pursue equitable access for historically disparate groups in society. This project connects
to that Grand Challenge by taking steps to ensure equitable access for individuals in this
population in behavioral health employment and treatment. The project presented here is a
mental health practice that employs neurodivergent and queer practitioners to provide services to
neurodivergent and queer clients. The practice focuses on accessibility, identity-based care,
while also supporting the potential self-employment of the practitioners. Design justice
principles were utilized to identify the core values of this project: accessibility, humility, non-
competition, and ethics. Building on these principles, design thinking was used to map out the
journey of a neurodivergent therapist, beginning with their initial engagement with the practice,
leading to successful self-employment and financial stability, while building their network and
investing in professional development. The goals of this project are highly attainable: to support
neurodivergent and queer practitioners while improving mental health outcomes for
neurodivergent and queer patients. Since the implementation of the pilot practice in 2021, it has
become evident that not only is this goal attainable, but it has the potential to have national
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implications for neurodivergent affirming care. This solution aligns with best practices by
adhering to the ethical standards of multiple governing boards (social work, counseling,
psychology, and psychiatry), while being consistently stakeholder-informed.
Since May 2021, the practice has become a successful multi-disciplinary group practice.
Building on that foundation, there are several steps for further implementation planned, including
national training cohorts, published results, and a replicable introductory training. The next
implementation phase of the project is to publish outcomes research that will demonstrate
evidence for the benefits of identity-based care to empower marginalized communities.
Publishing this work allows for practitioners all over the world to implement the strategies in
their own work. Additionally, the pilot is training therapists all over the country who want to
learn to better support neurodivergent clients, with current reach in Ohio, Kentucky, Alabama,
Tennessee, Kansas, Georgia, and Washington. Next implantation steps for the national training
are to produce an introductory manual with foundational information, and form cohorts of
neurodivergent practitioners who can connect with others in their state while going through the
training process. Further implementation plans focus applying for grants that will support the
practice to provide services, such as autism diagnostics and gender-affirming care, to the local
population free of charge.
Through these implementation steps it is estimated that the practice will continue toward
the goal of achieving equal opportunity and justice for neurodivergent and queer people who
engage with mental health care programs. By addressing both the employment of this population
as well as providing informed care for them, the landscape of mental health practice will adjust
to better support mental health outcomes for neurodivergent people with intersectional identities.

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Problem and Literature Review

The goal of the Grand Challenge to Achieve Equal Opportunity and Justice is to address
racial and social injustices, deconstruct stereotypes, dismantle inequality, and expose unfair
practices (Bent-Goodley et al., 2019). This Grand Challenge focuses on groups who have been
socially marginalized and are facing disparities. In every area of society, neurodivergent
individuals face disparities in access, equity, and justice. As a result, they are at risk of poor
health, high rates of unemployment/underemployment, and experience unfair practices at the
micro and macro levels as a result of policy and legislation (ASAN, 2022, Huijg, 2020). The
neurodivergent identity intersects with the other populations this grand challenge seeks to
address, through intersections in race, ethnicity, socio-economic status, and LGBTQIAP+
identities.
Neurodivergence is a term used by advocates of equitable approaches to variations in human
neurology, as a response to the perceived harm of the medical model, which focuses on “disease
and cure”, as well as the harm that typical standards of behavior have caused this population.
Some of the labels used to identify these neurocognitive differences are: autism, ADHD,
dyslexia, dyspraxia, dyscalculia, OCD, and Tourette’s (Huijg, 2020). The neurodiversity
movement has long purported that there are systemic disparities faced by neurodivergent
individuals, and the existence of these disparities is well-supported by academic research (Ee et
al., 2019; Huijg, 2020; Miller et al., 2021; Patel, 2022; Strand, 2017). The term “neurodiversity”
was created as a means to explain that these variations are naturally occurring in the human
species, and that this group is harmed by the societal standards for socialization, executive
functioning, and ways of thinking and experiencing the world. Essentially, they experience
injustice by being discriminated against because of how their brains work (Legault et al., 2021).
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The idea is express that just like all other types of biodiversity, there is neurological diversity
that naturally occurs in humans, and this naturally-occurring diversity should not be “othered”
(Huijg, 2020; Milton et al., 2020; Singer, 1988). The CDC reports that 1 in 36 people are
diagnosed with autism, and that 9.4% of people are diagnosed with ADHD (CDC, 2023).
However, literature indicates that autism and ADHD are presently and have been highly
underdiagnosed, especially in women and people of color, and that there is not a medical
explanation for more white males receiving a neurodivergent diagnosis than any other population
(Hernandez & Sparks, 2020; Jampel, 2018; Nussbaum, 2011; Turan et al., 2019; Wilson et al.,
2016). Underdiagnosis, misdiagnosis, and bias/discomfort in healthcare professionals has
exacerbated the disparities faced by neurodivergent people with intersectional identities
connected to gender, race, and sexuality, and this underdiagnosis has skewed the understanding
of how many neurodivergent people there really are (Eliot, 2019; Lai & Baron-Cohen, 2015;
Subbaraman, 1999).
The term “neurodiversity” can be used to describe a social context, just like race, gender, or
sexual orientation, and delineates between “neurodivergent” and “neurotypical” (Huijg, 2020).
While there is no actual clear separation between these two groups, medical models and societal
standards have created a strong divide. Because neurodivergent individuals do not share the
neurotypical expected standards for human behavior, they are often alienated and misunderstood
(Bruyère, 2023; Price, 2022). The disparities faced by this population also intersect with the
Grand Challenge to Close the Health Gap, as well as the Grand Challenge to End Racism (Bent-
Goodley et al., 2019). Texts about the Grand Challenges are insufficient and unfortunately do not
reference this group, even though they are such a large part of society, with estimates of 1 in 5
people (20% of the population) being neurodivergent in some way (Duong & Vogel, 2022).
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Literature indicates that the implications of intersectionality are often ignored in healthcare,
and in many settings, intersectionality has not been consistently used as a framework for research
that informs intervention designs to help vulnerable populations (Lacombe-Duncan, 2016; Yong
& Germain, 2022; Hernandez & Sparks, 2020; Semlyen et al., 2017). The theory of
intersectionality lacks an inclusion of neurodiversity as a social context category, exacerbating
the barriers faced by neurodivergent individuals, especially neurodivergent individuals of color
or those with LGBTQIAP+ identities (Semlyen et al., 2017; Weiss & Ramakrishna, 2006).
Much like race, gender, ethnicity, and sexual orientation, neurodiversity should be
considered as a social context with which to understand how a person may experience the world,
and should inform medical care and medical training, including in the mental health care sector
(Patel, 2021; Strand, 2017; Jampel, 2018; Mallipeddi & VanDaalen, 2021). Intersectional stigma
adds to the complexity of this framework, as individuals seeking medical care not only face
barriers connected to their intersectional identities, but additional barriers connected to the
implicit biases held by practitioners about each of those identities (Weiss & Ramakrishna, 2006;
Turan et al., 2019; Lacombe-Duncan, 2016; Semlyen et al., 2017). Wage gaps connected to race
and gender further this issue, as white/heterosexual/male/neurotypical practitioners often receive
the highest wages in medical employment, maintaining an unequitable environment for female,
neurodivergent, queer, or practitioners of color to engage with and impact the field (Karbeah,
2020; Mohammed-Strait & Umah, 2022; Warner & Lehmann, 2019). Individuals who face
stigma by healthcare providers have significantly more detrimental health outcomes, speaking to
a need for a further diversified medical community to serve them with a trained, intersectional
framework (Turan et al., 2019, Yong & Germain, 2022). For those working in the medical
system, cultural competency trainings are a standard requirement, but there are no requirements
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for neurodivergent competency, and neurodivergent individuals often avoid seeking healthcare
due to fear of uninformed medical service provision (Eagle, 2022; Khorasani et al., 2023; Turan
et al., 2019; Udonsi, 2022).
Research indicates that the social dynamics contextualized through the neurodiversity
paradigm are similar to societal dynamics connected to race, gender, and sexuality, and should
be acknowledged in research and innovations about diversity, equity, inclusion, and accessibility
(DEIA) implications and health disparity (Janse van Rensburg & Liang, 2023; Rosqvist et al.,
2022; Strand, 2017). There is very little available research regarding the impact of the pandemic
on neurodivergent communities, even though neurodivergent individuals have been very vocal
about these disparities and their struggles in online and public platforms (Miller et al., 2021).
In addition to issues of intersectional experiences of racism, sexism, and ableism connected
to neurodivergence, neurodivergent individuals also report significantly higher levels of
loneliness and loneliness-related health issues than their neurotypical counterparts (Ee et al.,
2019; Stickley et al., 2017; Miller et al., 2021; Strand, 2017). Loneliness both causes and
exacerbates medical issues, and this community is harmed by the struggle to access a safe and
informed social context (Miller et al., 2021; Quadt et al., 2020; Hernandez & Sparks, 2020). By
including neurodiversity as a social context in medical research, training, and care, research
suggests the potential for a societal shift in the way in which neurodivergent individuals are
perceived and cared for, reducing or eliminating disparities to healthcare (Mallipeddi &
VanDaalen, 2021; Jampel, 2018).
Stakeholders
Stakeholders connected to this problem are varied and interconnected due to the
intersectional prevalence of neurodivergence. Neurodivergent individuals are the core
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stakeholder, and can include neurodivergent individuals from every race, cultural background,
socioeconomic status, sexual orientation, age, gender, and social context group. These
individuals interact with the healthcare system, another key stakeholder.
Another key stakeholder segment is local and federal governments and politicians. These
individuals are responsible for informing legislation that impacts neurodivergent communities,
and political stakeholders have a significant amount of power over the access neurodivergents
have in society as well as decision power regarding funding that impacts neurodivergent people.
Political cycles and voting probabilities ultimately dictate policy advancement in these areas, and
may not be a reliable source for change. Along with politicians, employers and medical systems
create policies that impact neurodivergent individuals and are key stakeholders in addressing this
problem. Public and private agencies and their funders are crucial stakeholders, as they serve as a
primary source of advocacy for this population. There is significant division among the agencies
that serve neurodivergent communities, and there are pervasive disagreements about the
approaches that should be used to support this population. Autism Speaks and the Autistic Self
Advocacy Network are a clear example of this division, as they disagree on how to approach
autism care and what the end goals are, with Autism Speaks looking to find a “cure” for autism,
and ASAN looking to advance autistic standing in society while honoring and upholding autistic
identities (ASAN 2022, Autism Speaks, 2023). In this regard, ASAN actively speaks out against
Autism Speaks, which is a clear example of the divide even between organizations that seek to
represent the same population.
Further stakeholders include practitioners who interact with neurodivergent communities,
and the educational and licensing systems who train and create standards for clinical practice.
These stakeholders have the most direct access to and interaction with the neurodivergent
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community, and the most direct potential to perpetuate harm or to advance equity and justice.
Part of this practitioner community includes social workers, who directly interact with all the
populations that intersect with neurodivergent identities. Social workers should be trained,
prepared, and informed of neurodivergent needs and the prevalence of neurodivergencies that
intersect with other social contexts in order to provide useful support to these populations with
an appropriately intersectional lens. There is some resistance in this stakeholder population, due
primarily to misconceptions about neurodivergence, autism, and ADHD. Therapists who have
not received adequate or affirming training hold misconceptions that can cause them to feel deep
concern about the facets of the neurodiversity movement in regard to mental health care
(Bahnweg & Omar, 2023; Schuck et al., 2021). Examples of these misconceptions are deep
concern over which practitioner types should diagnose autism, a lack of awareness about the
existence of neurodivergent practitioners, a strict adherence to only one treatment intervention
for this population, and an idea that the neurodiversity movement is little more than a trend
(Sarrett, 2016; Walker & Raymaker, 2021).
An often forgotten stakeholder in this problem is the neurodivergent practitioner. Like
their neurodivergent counterparts in other fields, neurodivergent healthcare practitioners face the
same difficulties with finding and maintaining employment, in large part due to the social
standards of their neurotypical counterparts. There is a need for literature addressing the unique
experiences of neurodivergent therapists and medical practitioners in their fields. Research
indicates that patients who have providers who share aspects of their own identity (such as race,
ethnicity, neurotype, diagnosis, and gender) receive better care and have better health outcomes
(Byrne, 2008; McCowan et al., 2022; Meghani et al., 2009). The struggles to find employment in
their field for this stakeholder leaves a gap where neurodivergent patients could have a
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practitioner who understands and can support them well, but often they are paired with
practitioners who do not understand them and perpetuate structural harm against them.
Conceptual Framework

The conceptual framework of this project is built on addressing the current struggles of
neurodivergent populations: employment barriers, loneliness, high rates of suicide, provider
discrimination, and poorer health outcomes. It addresses the current barriers in the problem and
solution landscape: the divide between ideologies in the neurodiversity sphere, funding
difficulties, stigma, and misconceptions. This framework seeks to hold at the forefront the high
rates of unemployment and underemployment for neurodivergent people. Additionally, it seeks
to create safe and stable employment for neurodivergent practitioners, and uphold expertise in
the intersection of neurodivergent and queer identities. This conceptual framework is built on
holding affirming neurodiversity above all else in the project, as well as empowering
neurodivergent people to make changes in their lives. The future peer support program and group
therapy program will address the high rates of loneliness and isolation in neurodivergent and
queer communities, and is an integral part of the solution, utilizing social connection as a means
to combat loneliness, suicidality, and poor health outcomes.
A core tenant of the theoretical framework is that of identity-based care. This solution
specifically seeks to address the needs of neurodivergent and queer patients by empowering
providers from these communities to serve them, through the lens of peer support. Peer support
is highly effective and strengthens the relationship between patient and provider to support
progress. Individuals who utilize identity-based care do not have to expend valuable time,
energy, and resources educating their providers on what it is like to be them. They do not have to
worry that they will be misunderstood due to displaying mannerisms that are uncommon for
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neurotypical people. They may not need to wonder if something as simple as not wishing to
make eye contact will be misconstrued as a lack of trust or willingness to engage in treatment.
Identity-based care as a theoretical framework empowers progress to occur much faster and with
less emotional expenditures for the individual seeking care.
Part of the theoretical framework must support addressing the divide in the
neurodivergent community. Over time, fractures have formed in the neurodiversity advocacy
movement, creating division in the community. For example, the expansion of the autism
spectrum to include both Asperger’s disorder and Pervasive Developmental disorder has directly
impacted a divide between support needs for those autistic individuals who require less support,
and those who require ample support. In the Diagnostic and Statistical Manual (version V-TR),
support needs are medically placed under one “umbrella”, creating confusion and disagreement
regarding treatment best practices for these populations (Mattila et al., 2011). Previously, there
were different approaches taken to care for Asperger’s versus Pervasive Developmental
Disorder. Through the removal of the distinction between the two, the autism spectrum was
broadened and the community widened, but doors were opened for disagreement, harmful care
practices, and confusion about best practice (Volkmar & McPartland, 2014). By utilizing
neurodivergent practitioners (licensed mental health professionals) and peer supporters (trained
mentors), there is space for informed advocacy efforts from members of these communities who
can modify evidence-based practices as needed, based on the support needs of the individuals
they are serving, with the goal of bridging the gap between these communities.
The conceptual framework also seeks to address funding concerns, as there are many
barriers for neurodivergent and queer individuals to receive insurance coverage, but private pay
options are not feasible to serve large segments of these communities, especially when
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considering the high rates of unemployment and underemployment faced by this population. The
solution must then seek to address income disparity and decrease barriers to care.
The final barrier addressed in this conceptual framework is that of stigma and
misconception. There are many in the medical community who feel that there is only one “gold
standard” approach to neurodivergent care, related to the model of “treatment and cure” (such as
ABA treatment for all autistic people) (Dillenburger et al., 2014; Leaf et al., 2021). There is also
significant bias against neurodivergent and queer individuals in professional settings (Legault et
al., 2021), which this solution seeks to address by creating spaces that honor and uphold these
identities, instead of creating traditional spaces where these individuals are forced to conform or
mask their traits in order to receive equitable treatment. By utilizing a solution-focused
framework to address the barriers present, a multi-faceted approach is informed to address the
complex needs in the problem landscape.
In summary, if neurodivergent clinicians are trained to provide support to neurodivergent clients,
health outcomes may improve for this population. A successful pilot of this concept
opens opportunities for advanced peer support for all populations who have historically faced
medical/behavioral health care disparities in the United States. This solution has far-reaching
implications for the communities who are being served through affirming medical care as well as
employment opportunities for practitioners who are part of those communities. Identity-based
care requires that organizations intentionally recruit, train, and retain populations that typically
struggle to thrive in typical workplace settings, which impacts the landscape of employment
options for this population.

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Project Description

Based on this conceptual framework, the proposed solution is to change the landscape of
current mental health care offerings for neurodivergent and queer people, while simultaneously
addressing employment disparities for neurodivergent and queer practitioners. This project
upholds intersectionality and identity-affirming care, while empowering members of the
populations being served as catalysts for change, by launching of a first-of-its-kind private
mental health care practice: a group practice staffed primarily by practitioners who are both
neurodivergent and queer. The practice is called Reclaimed Divergence, honoring the long
history of neurodivergent individuals forced to attenuate their neurodivergent features in order to
belong. The name is confusing to those who do not understand neurodiversity, but for those
seeking affirming care, the practice name immediately indicates all they need to know about the
nature of the practice.
The additional focus on the intersection of LGBTQIAP+ identities in the practice is due
to the statistically higher prevalence of these identities in neurodivergent communities. Some
studies report that neurodivergent individuals are up to eight times more likely to identify as
queer in some way than their neurotypical counterparts (Dewinter et al., 2017; George & Stokes,
2017; Pecora et al., 2016; Strang et al., 2014; Weir et al., 2021). As such, an intersectional
approach is required to effectively serve neurodivergent patients in behavioral health care. This
solution also addresses employment disparities faced by neurodivergent and queer practitioners,
as well reduces the risk that neurodivergent and queer patients receive uninformed care. The
pilot practice launched in 2021 with two outpatient therapists working there (a counselor and a
clinical social worker) who share these intersectional identities. Each therapist served a caseload
of approximately 35 clients. As of the time of this writing, the pilot practice is staffed with a
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medical director, two nurse practitioners, a psychologist, and 10 clinical social workers and
counselors, along with a small administrative staff. Most of the therapists are neurodivergent
and/or queer themselves; the team also reflects the benefits of neurodiversity by holding a
willingness to bring on highly informed and experienced neurotypical practitioners.
As of the time of this writing, the pilot practice has served over 650 clients in the
Cincinnati, Ohio area since its launch in June 2021. This pilot practice is in the first phase of an
integrated effort to address neurodivergent health disparities. The methodology is simple: trained
practitioners who are neurodivergent will provide more effective care to neurodivergent clients,
improving health outcomes, decreasing suicide risk, and promoting social inclusion through
affirming care. Initially, the pilot practice’s primary role is community establishment and
research: establishing evidence through the data that health outcomes are truly improved when
clients and practitioners share the same intersections in identity. In a later phase of the project,
the creation of a peer support specialist program will begin, training individuals who desire to
support their communities as peer mentors. A peer mentor is an individual who is not a licensed
practitioner that receives particular training to work with individuals who are their peers in some
way (in this case, neurodivergent peer mentors working with other neurodivergent individuals).
This iteration more fully honors the conceptual framework that addresses multiple barriers and
disparities faced by the populations served. It is expected that disseminating evidence and
establishing an evidence-based practice that can be used in other practices will take about 10
years. Throughout the course of those 10 years, it is expected that the pilot practice will grow,
and will support the creation and continuity of other practices with a similar focus.
Equally important to this solution is the financial stability and career stability of the
neurodivergent practitioner. Practitioners join the practice join as contractors, making them self-
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employed and the owners of their own labor from the beginning. They are paid at or higher than
current market rates, making the pay highly competitive for the local market. They are provided
with significant support from the practice, which takes care of marketing, electronic health
record access, mutual support, and scheduling, along with licensure supervision for dependently
licensed practitioners. While with the practice, interested practitioners also receive a 6-12 week
intensive diagnostic evaluation training where they learn how to use standardized testing for
autism, ADHD, and other diagnoses, by shadowing a trained diagnostician. In addition to not
having to pay for the training, they receive compensation while they are in training, and have the
opportunity to assist with every part of the assessment process for detailed, hands-on learning.
When training is complete, they become evaluators who can help to meet the extremely high
need for diagnostics. Through this training program, waiting lists in the area for informed
diagnostic evaluations have decreased from 8 months to 4-6 weeks.
The pilot practice operates without any non-compete clauses, so practitioners are free to
open their own practices at any time, in order to advance the local options in the community for
neurodivergent and queer clients. Those practitioners who wish to receive business coaching and
mentoring do so from the practice founders, who have each successfully launched and
maintained multiple businesses, and when they are ready to launch their own practice, they are
permitted to take their current clients with them in order to start up with a stable and thriving
practice. Self-employment for neurodivergent practitioners is empowering and promotes greater
sustainability, and taking a non-competitive approach is crucial for the pilot practice to honor the
goal of employment security and support for neurodivergent and queer practitioners, while
focusing on providing the best possible care to clients and the best possible workplace for
neurodivergent and queer practitioners.
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Theory of Change
The link between the proposed solution and expected outcome is best explained by the
tenants of peer support theory, neurodiversity theory, and social cognitive theory. Neurodiversity
theory, as referenced above, purports that the neurodivergent “conditions” studied in medicine
are natural variations that occur in human biodiversity, and should be accepted and honored
without stigma or discrimination. Current health care and labor regulations require that
neurodivergent conditions be given a label for those individuals who wish to use insurance
coverage, receive medication, or receive accommodations at work or at school. Under this lens,
neurodiversity theory does not reject the medical model, but works with it to empower and uplift
neurodivergent people.
Peer support theory provides evidence to support the idea that health outcomes are
improved when practitioners share aspects of identity with their patients (Hernandez & Sparks,
2020; Mead et al., 2001). Peer support in behavioral health has established outcomes in the
domains of mental health and overall well-being (Myrick & del Vecchio, 2016; White et al.,
2020), and serves as a crucial foundation for several aspects of this innovation. Throughout the
history of mental health care, one foundational aspect has proven true in demonstrating positive
health outcomes: the relationship between patient and provider (Beckman, 1994; Krupnick et al.,
2006; Pines & Maslach, 1978). Identity-based care supports this relationship, by allowing clients
and providers to have shared experiences that create critical understanding for providers of their
patient’s potential trauma, communication needs, and useful interventions to employ in the
working relationship.
Social cognitive theory is a human-in-environment theory, emphasizing the impact of the
social environment on motivation, learning, and self-regulation (Schunk & Usher, 2019). The
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social cognitive theory serves as a critical component of a safe and supportive environment for
the populations being served. This may improve community wellbeing, while directly addressing
the needs of individuals. This directly connects to the neurodiversity theory coined by Judy
Singer (referenced previously) which focuses on creating safe environments for neurodivergent
individuals and groups, in order to improve their overall quality of life.
By themselves, none of these three theories hold a strong enough foundation to
adequately impact the current mental health outcomes of neurodivergent and queer individuals.
However, the combination of neurodiversity theory, social cognitive theory, and peer support
theory creates a strong foundation for planning for impactful and systemic change. This
combination is not one that has yet been utilized as a means to solve the problem of
neurodivergent/queer disparities. It is clear that this problem has not yet been solved because
current approaches typically are focused strictly on the medical model or the self-advocacy
model, and historical approaches focused on the social adherence of the neurodivergent person to
neurotypical norms. An effective multivariant change approach has not yet been employed. By
connecting these theories of change to specific, interconnected interventions, significant change
can be achieved.
Presented in the appendices, the Logic Model for the framework addresses these barriers
through the identification of strategies, outputs, and outcomes. The logic model utilizes some of
the foundations of the medical model of care, including trained experts providing treatment to
patients. It further builds on the concepts of peer support and identity-focused care to create
effective and affirming care modalities. The model explores the multivariate approach of
employment retention for neurodivergent practitioners, as well as the efficacy of mental health
care for neurodivergent patients. The logic model also examines the creation of a replicable,
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evidence-based practice for modified mental health approaches to care that is formed out of the
data collected on health outcomes for clients who engage with the pilot practice and receive
identity-based care.
Solution Landscape

In recent years the awareness of this problem has grown, and consequently, the solution
landscape has grown considerably. The landscape includes the social model of disability, self-
advocacy efforts, small-scale identity based care practices, and social media efforts to combat
misconception. Explored here are the social model of disability theory, self-advocacy, social
media, workplace recruitment programs, medical model approaches, and the building of
awareness through the arts and popular media. There have also been many solo mental health
care practices throughout the United States where neurodivergent and/or queer practitioners
openly disclose their identities to better support clients. However, there is not yet a formal model
of care through which a census estimate can be derived.
Globally, the Social Model of Disability has been utilized to reduce stigma against
individuals with visible disabilities, by affirming the personhood of those who (for example)
require assistive devices through honoring that person as the expert of their own experiences and
needs (Barnes, 2019). Some have suggested expanding this social model to include
neurodivergences, by changing the narratives used in publications and communications to shift
the expertise about the neurodivergent individual onto the individual themselves, as a means to
decrease barriers and discrimination (Chapman, 2019). The social model of disability can be
effective in informing practitioners about disabilities, but through the current framework it puts
the ownership onto the neurodivergent person to expend their own emotional labor to educate the
more privileged group about their own experiences. Critics of the Social Model of Disability say
23

that this model does not account for socio-cultural influences globally on autistic people, and
seeks simply to change wording and marketing efforts, without sufficient research or
understanding on the barriers faced by this population, and consequently, is an inefficient
solution (Jurgens, 2023).
Since the neurodiversity movement began in the 1980’s, self-advocacy has been a core part
of the solution landscape. Organizations like the Autistic Self Advocacy Network (ASAN)
gather autistic individuals together to challenge harmful policies, to provide public education
opportunities about autism, and to advance autistic people in society. ASAN’s tagline is
“Nothing about us without us,” challenging the plethora of policy decisions made by
neurotypical people that impact autistic people, without sufficient autistic input (ASAN, 2023).
ASAN provides education, resources, and policy advocacy, and is intentionally staffed entirely
by autistic individuals.
An important part of self-advocacy for neurodivergents is the use of social media platforms,
which has increased since the start of the COVID-19 pandemic, and has effectively raised
awareness of neurodivergence in the general population (Hotez et al., 2023). The creation of
organizations that use the digital platforms to reach neurodivergent individuals became crucial
during the pandemic, and organization such as Ourtism were founded. Ourtism focuses on virtual
support and coaching for autistic youth and adults (Estelle, 2022), and is also staffed and run
solely by autistic individuals who offer coaching and virtual social connection groups for other
autistics. However, much like the social model of disability referenced above, the self-advocacy
model again places the ownership for equity and change onto the neurodivergent person who is
experiencing the disparities, with little emphasis on allied advocacy. The primary flaw of the
self-advocacy movement is that it effectively silences the voices of non-speaking or significantly
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disabled neurodivergent people, who are not able to advocate for themselves through these
channels. There has been a harmful observable trend in the self-advocacy movement of
neurodivergent individuals shutting out those who seek to advocate for their non-verbal or
disabled loved ones if those individuals are not neurodivergent themselves.
Workplace programs have been created to recruit neurodivergent individuals, such as The
Employer Assistance and Resource Network on Disability Inclusion, which serves to assist
employers in recruiting and retaining skilled neurodivergent talent (EARN, 2023).
Neurodivergent individuals who have engaged with these programs have reported that the
disclosure of their diagnoses in the workplace has led to additional workplace discrimination,
and many have consequently found the program unhelpful. There is a significant disparity in
accommodations for individuals with invisible disabilities, and many describe difficulties
obtaining workplace accommodations, even after being diagnosed with a recognized disability
(Mellifont, 2022).
Further solutions to promote social change lie in awareness efforts, such as Autism
Awareness Month, which has been effective in increasing conversations about autism. In popular
media, TV shows like Atypical, Love on the Spectrum, The Good Doctor, and Everything is
Going to Be Okay have sought to highlight autistic characters and autistic actors. These shows
have served to bring autism into mainstream conversation, but have been criticized for using
neurodivergence as a means for neurotypical producers and actors to gain money through
entertainment. Traditionally, these shows and movies portray stereotypical white-male
presentations of autism, or the extremely rare savant presentation, which has also been criticized
as reinforcing unhelpful stereotypes (Matthews, 2019; Moore, 2019).

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Prototype
The prototype developed for this project is designed to showcase both the introductory
training of this project, along with the practice itself that was developed with practitioners
providing identity-based care. This high-fidelity prototype has two parts: the website that
outlines what it looks like for practitioners to engage with clients through identity-based care,
and an introductory training PDF designed as an entry-level course into the world of
neurodivergent affirming care. The PDF is a mock-up for the creation of an eventual virtual,
asynchronous training opportunity. The website is accessed through the QR code on the third
page of the training manual, or through the link provided in Appendix A. This prototype is the
most appropriate format for this project because it addresses the duality of the project: the
practitioners themselves who intentionally self-disclose identity to connect with their clients, as
well as the training materials used to assist other practices and practitioners to grow in their
understanding of neurodivergent affirming care.
The prototype is being used to test the specific areas of introductory training. In its first
iteration, feedback from 57 autistic individuals noted that the training was too advanced, and
skipped over very foundational and important introductory information (for example, the
meaning of the word “neurodivergent”). The second iteration of the training found that it was
much more useful as a foundational training tool, but feedback from autistic practitioners said
that it did not adequately cover the many misconceptions faced by neurodivergent people, which
was perceived as an important foundational area of study by the trainees. In the second iteration,
feedback about appearance was also provided, and the suggestion was made to create a product
that is more pleasing to look at than a typical word document. The current iteration of the project
is what is presented here. It is an illustrated PDF manual with web access provided via a QR
26

code where trainees can learn more about the practice and how to promote their own identity-
based care work (if relevant). This version presented here was presented to a group of primarily
neurotypical practitioners in Cincinnati. Their feedback was that it was a paradigm-shifting
presentation for them, but they found themselves wishing that “next steps” had been provided as
a part of the training, in the form of readings, resources, and additional training and coaching
opportunities. With that feedback, a 4th edit is underway to address these concerns.
This prototype has been a valuable tool to assess what information is most important to
share in a foundational course about neurodivergent affirming care, as well as the needs of
neurodivergent and neurotypical practitioners in evaluating and applying the information. As the
prototype continues to evolve, it will serve as an invaluable resource to the goal of improving
mental health outcomes for neurodivergent individuals.
Methodology
The principles of design thinking were used to develop this project. First, core values to
guide the project were identified through the formation of design criteria and design briefing (see
Appendix E). Next, a year of full-time field work was conducted with neurodivergent patients in
mental health care, which allowed for gathering data on the anecdotal experiences of
neurodivergent and queer individuals engaged with mental health care systems. Building upon
this, interviews were conducted with 20 mental health care practitioners, 17 of which were
neurodivergent themselves. Through these interviews, themes emerged around the need for
mental health care that was specifically tailored to people with the intersectional identities of
neurodivergent and LGBTQIAP+, because the therapists who were trying to serve this
population were so inundated with referrals that patients were waiting months (or longer) to
receive informed and affirming care. After the interviews were completed, the design for the
27

practice was created and launched in May of 2021. Current methodology for implementation is
focused on initiating a formal program evaluation to publish outcomes research regarding the
efficacy of identity-based care, both for patients and providers. Interviews are being conducted to
determine the most effective way to launch a peer-support coaching program, where
neurodivergent and queer individuals can learn how to provide peer support and mentoring to
others who share their identities.
The market for identity-based care design is vast and needed. Individuals who are
employed in workplaces where others share their social identities are more likely to have higher
job satisfaction and experience lower rates of workplace discrimination (Banerjee & Perrucci,
2010). Additionally, neurodivergent patients are far more likely to choose to work with a
neurodivergent practitioner than a neurotypical one, in order to decrease their risk of feeling
unsafe or misunderstood by their healthcare providers (Duong & Vogel, 2022; McCowan et al.,
2022; Shaw et al., 2022). Because neurotypical practitioners report high rates of discomfort
working with neurodivergent patients (Ortiz et al., 2023) there is also a market for trainings led
by neurodivergent practitioners to be provided to neurotypical practitioners, allowing
neurodivergent practitioners to be paid for their time and efforts educating others, while
decreasing the misconceptions commonly held by neurotypical practitioners. Because the
concept of neurodiversity has become more well known, it can be used by organizations to
appeal to a broader market, so there is significant opportunity in the current market for
neurodivergent practitioners to step in and provide clear and accurate insight into the needs of
neurodivergent individuals in society.
The pilot practice is currently financed through self-pay mental health care sessions, as
well as national training for clinicians who are learning how to provide diagnostic assessments
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that include informed assessment for autism, ADHD, and other neurodivergencies. The next
phase of funding is to complete grant applications that will allow for the provision of free and
reduced rate services for diagnostic assessment, group therapy, gender-affirming care, and more,
and will cover research expenses so that the program can be improved based upon the evidence.
To assess the project’s efficacy in achieving social change, data collection markers will
be established that track long-term progress of both the neurodivergent practitioners and their
clients. Staff metrics will measure on tenure, job satisfaction, and rates of successfully meeting
job expectations. Patient metrics will measure goal attainment, patient satisfaction, and patient
reports of receiving informed vs uninformed care. Currently, patient data is being collected every
3-6 months and in future phases of the project, will be analyzed to determine efficacy.
Implementation Plan
Initial implementation of this project began with a financial investment of $15,000 from
the design team/shareholders to secure office space, furnishings, electronic health record access,
malpractice insurance, and email server access. Although marketing was a planned
implementation step, it was not needed as the practice unexpectedly began with a waiting list of
43 clients in the first week of opening, primarily from word-of-mouth communication in the
area. This is attributed to the significant need in Cincinnati, Ohio for this type of informed and
affirming service, along with the fact that the designers were already well-known in the area for
their work providing affirming care as small, individual practices. From initial implementation,
the practice was funded through therapy sessions, group therapy sessions, and diagnostic
assessments. The practice grew quickly with several neurodivergent practitioners who were
looking for safe employment, which increased both profit and expenses considerably. See
Appendix C for a detailed line item budget for 2022, 2023 to-date, and an estimate for 2023 and
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2024 based on current projections. Moving forward, the most significant part of the financial
plan is to begin the grant application process in October of 2023. The goal for grant-based
funding is to expand the service offerings of the practice, with programs such as free gender-
affirming care, free group therapy, and free peer-support coaching. Additionally, grants will be
sought to fund the creation and publication of a training program for practitioners to learn more
about neurodivergent and queer patients and how to best serve them.
The foundational part of the implementation plan for this project is the cyclical EPIS
Framework (Exploration, Preparation, Implementation, Sustainment) (EPIS, 2023). See
Appendix E for a chart on the EPIS considerations that were made in this implementation. The
framework prioritizes both inner and outer contexts of the implementation, focusing not just on
the practice itself, but external community and stakeholders as an equally integral part of the
process. Adhering to the structure of the EPIS framework, stakeholders are involved in every
step of the implementation cycle. Although the practice is staffed by stakeholders, it is
imperative to include community voices outside of the practice as well, to ensure adherence with
current market needs, and matching current best practices. In the exploration phase, the local
market was explored, field work was conducted, and stakeholders were identified and
interviewed. In the initial preparation, ethics and laws were researched to ensure careful
coherence with expectations. Leadership roles were developed, and plans for neurodivergent
practitioner career development tracks were made. Implementation occurred through the actual
launching of the practice after preparation was complete. Currently, the EPIS framework is being
used to implement new and expanded services, while examining and improving those that are
already offered. In the current exploration phase, grant opportunities are being researched and
30

stakeholders are being interviewed. Simultaneously, preparations have began to launch outcomes
research that will be published.
Communication strategies in this implementation have grown to focus on connections
with other group practices for mental health care in Cincinnati, Ohio. Outreach has been
launched to communicate with practices who are known for providing unaffirming care, or
holding misconceptions that impact their work. The approach of the pilot practice is to offer
training to these practices, who then have the opportunity to learn more about the population and
adjust their thinking accordingly. This has begun implementation, and has been highly effective,
and also significantly increased referrals for the pilot practice. The practice is also involved in
advocacy efforts, working to disseminate accurate information to practitioners all over the
country in order to increase accurate communication about these populations and true best
practices for care.
Challenges
So far the primary challenge in the implementation of this project has been securing
funding in a way that counteracts financial barriers to healthcare access. While the practice does
offer out-of-network insurance billing support, insurance reimbursement rates are insufficient for
the practice to be able to sustain the robust and varied services that are currently offered, while
ensuring the clinicians are paid a fair and competitive wage. Future steps to secure grants will
lower costs for clients and will also allow the practice to reach more individuals. Presently, low-
fee sliding scales are offered to those who need it, and in some cases, pro-bono services have
been offered. The practice also operates on the idea that individuals should not be punished for
executive function or disability, and as such there are no cancellation fees ever charged for any
reason.
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Additionally, there are challenges connected to combatting criticism from mis-informed
practitioners who have not learned about the intricacies, standards, and rules about autism
diagnostics. When the practice first launched, several local psychiatrists and psychologists were
frustrated that people who were not under those two specific professions were diagnosing autism
and ADHD. Some even publicly stated that they did not think this was allowed, and felt that the
practice was operating illegally and taking advantage of unsuspecting and vulnerable clients.
This has been addressed through intentionally providing updated and accurate information to
better support a community understanding of the strengths of neurodivergent affirming care.
Through careful communication as well as the public sharing of the laws, rules, and best
practices surrounding standardized testing and diagnostics, many of those practitioners who were
initially concerned became some of the primary referral sources to the practice and have had the
opportunity to learn accurate and useful information about providing diagnostics to this
population. The specific steps to accomplish this will be an important part of uptake of this
model beyond Cincinnati, where it is currently based.
Occasionally, the practice receives some blatant transphobic communications from
individuals in the community who are not supportive of gender-affirming care. This has been a
challenge but the practitioners have not had to receive these communications themselves, and it
is easy to filter through them. Professionals who send these messages are reported to their
employers, and others are simply sent educational resources to expand their thinking. Individuals
who send abusive messages are blocked, and there are safety and contingency plans in place
should they be needed.
A leadership strategy that focuses on individual-led standards is crucial when employing
neurodivergent practitioners. Leadership in the practice utilizes the Situational Leadership
32

Model, as it allows for individualized support in a way that does not penalize those who require
extra support. Situational leadership consists of four levels of readiness, ranging from high
support needs to autonomy in meeting job responsibilities and task completion, and focuses on
reallocating the power of the leader for a more effective, collaborative approach (Hersey et al.,
1979; Sanchez & Wiesman, 2022; Thompson & Glasø, 2015). It takes a very affirming approach,
essentially that leadership strategies must be adjusted based on what level a person is at on any
given task. This affirming approach mirrors the best practices for neurodivergent affirming care,
which focuses less on social adherence, and more on utilizing the strengths of the person to
empower them to meet needed tasks in a way that works best for them.
Ethical Consideration and Applying Design Justice Principles

The development of this project includes an ongoing consideration of ethical concerns,
the principles of design justice as the parameters for ethical decision making. One concern early
on in the implementation of this project was raised: does intentionally hiring
neurodivergent/queer individuals require discrimination against neurotypical/hetero-normative
individuals who may want to join the practice. Since implementation, the practice has been very
intentional to honor diversity, and has not screened out anyone for not being neurodivergent or
queer. Most of the therapist who applied to work with the practice did hold both of these
identities, but the practice also employs practitioners who are not neurodivergent and queer
personally, but are highly informed and hold humility in their work. By only hiring individuals
of a particular demographic, the care that can be provided to clients is inhibited, so the practice
remains open to all diversity (including neurodiversity) when hiring. The practitioners openly
disclose aspects of their identity that they are comfortable sharing on their biographies on the
33

website (see Appendix B for the webpage link). This allows potential clients to determine before
booking who they relate to and might like to work with.
An ethical consideration the design continues to explore is that of funding and the
financial responsibility of clients. The practice does not contract with any insurance companies
and operates on a self-pay basis. A common criticism of self-pay practices is that they inhibit
access to those who do not have the economic resources to pay out of pocket for their medical
care. The practice attempts to address this by offering low rate sliding scales and assisting with
out-of-network billing claims, and thus far has been effective in creating opportunities for those
who desire to work with the practice but cannot pay a full fee. When considering the many
implications of insurance coverage for an autism diagnosis, many individuals prefer to have their
diagnosis completely protected and confidential, and do not want their insurance company to be
informed. By not contracting with insurance, client confidentiality can be well protected. The
other benefit to self-pay is that the clinicians are able to provide longer sessions to their clients
with more intensive care as needed, without the timing restrictions of many insurance plans. To
make care even more accessible, further iterations of the project include applications for grants
in order to be able to provide many services for free to the community (such as gender affirming
care letters, autism diagnostics, and group therapy).
The principles of design justice are imperative in ensuring that this design is clearly
justice oriented. Design justice principal number 1 states “We use design to sustain, heal, and
empower our communities, as well as to seek liberation from exploitative and oppressive
systems” (Design Justice Network, 2016). This design justice principle is the driving force for
the ethical and impactful implementation of this project. By utilizing neurodivergent and queer
practitioners, these communities can heal from within. Creating a safe space for
34

neurodivergent/queer practitioners to maintain employment at competitive rates of pay supports
the liberation from oppressive systems mentioned in the design justice principle. The affirming
perspective adopted by the practice also supports the design justice principle that states, “We
believe that everyone is an expert based on their own lived experience, and that we all have
unique and brilliant contributions to bring to a design process” (Design Justice Network, 2016).
This design is continuously informed by the designer’s lived experience, as well as those of the
practitioners involved in the practice and their clients. An affirming perspective requires a
commitment to honoring everyone as an expert of their own experience and adjusting the design
accordingly.
Conclusion and Implications
This practice is the first of its kind: a group practice owned by and staffed with primarily
neurodivergent and queer practitioners who openly serve neurodivergent and queer patients for
diagnostic testing, psychiatric mediation management, outpatient individual therapy, and
outpatient group therapy. The practice is innovatively designed by and for individuals in a
population that does not currently receive adequately safe and informed care in the current
landscape. The practice is run by and staffed primarily by autistic clinicians, and has proven in
its first two years of implementation that autism is not a barrier to a providing high quality care,
but a strength that allows for neurodivergent clients to thrive under the care and support of their
autistic practitioner. Currently in the Cincinnati, Ohio area, 17 local practitioners have reached
out and requested formal training, supervision, and discussion regarding providing a safe
environment for neurodivergent practitioners and providing informed care to these clients after
realizing the incredible impact the practice is having on the local landscape. Other practices have
requested training for their entire group in order to better serve this population. The simple
35

existence of this affirming practice is already changing Cincinnati, Ohio into a place that can be
well known for affirming care. By pursuing the next phases of implementation explored
previously, it will be possible for that impact to spread nationally. This practice and the
principles on which it is built play an integral role in changing the landscape of mental health
care in the United States away from a social adherence and cure model to a model that affirms
identities and challenges harmful and unnecessary societal standards for behavior.
The initial implantation phase for this project has shown potential for significant social
impact, both for practitioners and patients who are neurodivergent, queer, or both. The
practitioners report high rates of job satisfaction and comfort in their roles, and patient outcomes
surveys report high patient satisfaction. A crucial next step is a formal program evaluation,
which will allow for publishable research regarding the effectiveness of identity-based care for
neurodivergent and queer patients and providers. In doing so, the goal to replicate the mindset
and mission of the pilot practice can be more readily attained by disseminating information for
others to learn from and build or adjust their own practices in a way that positively impacts this
population. In October 2023, the grant application process for the practice will formally begin,
with the goal of securing a $25,000 grant for 2024 that will allow the practice to being to provide
free gender-affirming documentation to patients who desire to socially or medically transition
and require documentation to do so. Larger grants will also be applied to in order to evaluate,
publish, and disseminate the training program launched by the pilot practice.
While this pilot practice is the first of its kind, it will not be the last. Through the national
training of clinicians all over the country provided by this practice along with the strong growth
of the neurodiversity movement, it is estimated that it will become much more common for such
practices to exist. This practice exists as a support, a launching point, an example, and a catalyst
36

for change for other practitioners who seek to become more affirming in their care. Through this
project, mental health care in the United States is expected to dramatically improve for
neurodivergent and queer individuals, improving health outcomes and quality of life.

37

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48

Appendices

Appendix A – Logic Model

49

Appendix B- Prototypes

1. Practice Website: https://www.reclaimeddivergence.com/

2. Journey Map for Practitioner Experience:

50

Appendix D- Design

DESIGN BRIEF
PROJECT
DESCRIPTION
The problem: Individuals with intersectional LGBTQIAP+
and neurodivergent identities receive inadequate understanding
and support from health care providers. Providers who share these
identities are at risk of unemployment or underemployment. To
solve this problem in the behavioral health, a pilot practice will be
created that is staffed by neurodivergent and queer practitioners,
in order to create stable employment opportunities while
improving health outcomes for the population.
SCOPE The scope of this project is in peer support and mental
health care. The constraints of the project are laws around
providing mental health care, as well as ethical codes and
standards of social work, counseling, psychiatry, and psychology.
The practice must honor all of these while maintaining a
neurodiversity-affirming lens.
USERS AND
STAKEHOLDERS
This design is for individuals who hold one or more
identities under the neurodivergent and LGBTQIAP+ umbrellas.
Additionally, loved ones of neurodivergent individuals should be
considered, as well as practitioners who serve these populations
but are not a part of them.
51

EXPLORATION
QUESTIONS
What makes a medical interaction “safe” and “affirming”?
Are current best practices enough to adequately support
these populations?
How will this practice be different than current private
practices?
How should funding be approached?
EXPECTED
OUTCOMES AND
SUCCESS METRICS
After this project succeeds, the mental health care sector in
the United States will be safer and more affirming for both
practitioners and patients who hold neurodivergent and queer
identities. Providers will generally become more aware of the
unique needs of these populations, and mental health outcomes for
these populations will improve.
Metrics to assess success of this project on a mezzo level
are:
1. Employment retention and satisfaction of
neurodivergent and LGBTQIAP+
practitioners
2. Client satisfaction and outcomes
3. Local impact on the mental health market
and standards
On the macro level:
1. Decreased suicidality for the populations
2. The practice model is replicated all over the
United States
3. Practices who are not staffed by these
populations are still informed and affirming
of their patients who hold these identities
52

DESIGN CRITERIA
NON-
COMPETETIVE
The project will not operate under a focus on competition.
There is no shortage of practitioners, no shortage of
neurodivergent/queer people, and no shortage of a need for mental
health care. As such, it impedes progress toward the goal of the
mission of the project if the practice holds important resources and
information as proprietary. Practitioners will be free to hold other
positions, to pursue their own interests, and to launch their own
practices at any time.
ACCESSIBLE The project will hold a commitment to accessibility in all its
forms, ensuring ADA compliant office spaces and options for
sensory comfort. Executive function support will be provided to all
practitioners, and no unnecessary work or paperwork will be
required. The practice will utilize sliding scale measures and offer
out-of-network billing support, and will be committed to finding
ways to provide free services to those who need them.
ETHICAL The project will continually be reassessed to ensure that laws,
ethical standards, and best practices are being utilized and adhered to
INFORMED
AND HUMBLE
The designers will utilize not only their own perspectives, but
those of many others in the community. Call-outs and corrections
will be patiently received. Designers will not extort emotional labor
53

out of any member of an impacted group, and will always reimburse
stakeholder design partners for their time, energy, and efforts.
54

Appendix E: EPIS Framework

Abstract (if available)

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Asset Metadata

Creator Morton, Emiley (author)

Core Title An intersectional approach to addressing the grand challenge to achieve equal opportunity and justice for neurodivergent individuals in mental health care

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 2023-08

Publication Date 08/09/2023

Defense Date 07/27/2023

Publisher University of Southern California. Libraries (digital)

Tag ADHD,autism,behavioral health,Gender identity,neurodiversity,OAI-PMH Harvest,sexual identity

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Manderscheid, Ron (committee chair), Ostrow, Laysha (committee member), Schwartz, Sara (committee member)

Creator Email emiley@reclaimeddivergence.com,ermorton@usc.edu

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