Key Points

• Neurodivergence describes a person whose brain functions differently from the majority of people; autism and social anxiety are neurodivergent conditions.

• There are a lot of undiagnosed and self-diagnosed neurodivergent people. Most are elder millennials and older. They’re known as “the lost generation.”

Note: Accommodating any client’s needs should always be weighed against your needs and limitations. You’re not the right therapist for everyone, regardless of neurotype.

Neurodivergence is a term that was barely known by the general population a few years ago. Yet, according to the National Institutes of Health, an estimated 15–20 percent of the world’s population exhibits some form of neurodivergence.¹ This means you likely have several neurodivergent clients—and that means you need to know how best to meet their needs. Much of the following information is simplified and generalized because you don’t need the ins and outs of each diagnosis or Venn diagrams of overlapping traits to accommodate the biggest needs of your neurodivergent clients. 

Some of the general categories of differences that neurodivergent people deal with include sensory and motor control, information processing, executive functioning, perception, language processing, and communication. Someone who isn't neurodivergent is called neurotypical, and it's not uncommon for a neurotypical person to have some of these issues as well, just to a different degree or for a different reason. So, understanding these needs has the bonus of helping make many of your neurotypical clients more comfortable when they come to you for massage and bodywork services.

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, 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.”² That’s important because there’s no single definition of “normal” with respect to how the human brain works. 

It’s important to note that neurodivergence refers only to neurodevelopmental differences, not intellectual impairments. Although these can sometimes co-occur, auditory, visual, speech, and social difficulties should not be conflated with intellectual deficits.

Along the same lines, it’s important to not compare neurodivergent people and traits to one another. Many traits are present across multiple conditions, and no two people with the same conditions have the same set of traits that manifest in an identical manner. To borrow and tweak a great phrase from the autism community, “If you’ve met one neurodivergent person, you’ve met one neurodivergent person.” Fibromyalgia is an apt massage-related analogy for this. Not all fibro patients have the same tender points, pain patterns, set of pain-flare triggers, or length and intensity of a pain flare. Apply that to the brain, and you’ll start to understand neurodivergence. For this reason, it’s bad form to compare one neurodivergent person to another.

We’ve learned a lot about neurodivergence over the last few decades, and diagnostic criteria have changed drastically to reflect that knowledge. For instance, did you know that when I was a kid in the 1970s, autism was not its own diagnosis? It was listed as part of childhood schizophrenia. Experts at the time thought attention deficit hyperactivity disorder (ADHD) was something you grew out of. Because of this, there are a lot of undiagnosed and self-diagnosed neurodivergent people out there. Most are elder millennials and older. They’re known as the “lost generation,” and some of them are probably your clients.

So how can you tell which clients are neurodivergent and which are not? You can’t. You can’t even ask them to check the neurodivergent box on the health history form, because many in the lost generation don’t know they’re neurodivergent; they just know they’ve struggled with certain things their entire lives.

Understanding neurodivergence means making fewer assumptions about your clients, and also recognizing how every aspect of a massage appointment—from booking to checkout—might affect them.

Lucky for you, most massage spaces are well-suited for many neurodivergent people, but chances are good you may need to make some tweaks or offer an occasional accommodation to best serve this population. Let’s find out how. 

Sensory Issues

One of the hallmarks of several neurodivergent conditions is sensory issues. Like practically everything else in life, sensory issues exist on a spectrum that’s not linear. My favorite analogy is to a bowl of Skittles, where each color is a different trait. Each person who reaches in and grabs a handful of Skittles will grab a slightly different mix. That’s the sensory spectrum I’m talking about. Bonus: The Skittle analogy is also perfect for the “autism spectrum” (please don’t use this term unless your client uses and prefers it) and for the vast number of overlapping traits that people of many neurodivergent diagnoses may share.

Neurodivergent people can be sensory avoidant, sensory seeking, or both. The degree of sensitivity can vary from one day, hour, or minute to the next depending on the amount of sensory, mental, and emotional input they’ve already processed. The same is true of your neurotypical clients who are stressed out, get migraine headaches, or experience hormonal fluctuations.

Visual

For many neurodivergent people, lighting is a major sensitivity. Bright and fluorescent lights can wreak havoc with the neurodivergent nervous system and cause a great deal of pain and sensory overload. They can also be problematic for many migraineurs and people with certain eye conditions, such as glaucoma. While this shouldn’t be an issue in your treatment room, it could be a problem in your waiting room or other nontreatment spaces. Along with sensitivities, there are visual processing issues; dyslexia is the most well-known of these, with 20 percent of the population estimated to be dyslexic. To best serve your dyslexic clients, you’ll want to make sure that as much of your written communication as possible (i.e., website, emails, and intake and consent forms, whether printed or online) are dyslexia-friendly. 

One last visual issue you may need to accommodate is aphantasia, which is a decreased or total inability to see things in your mind’s eye. This will only affect you if you do guided meditations or visualizations with your clients. Some people with aphantasia have developed work-arounds for their diminished or lack of internal imagery, but some have not. For this reason, I suggest asking clients if they’re open to a short, guided meditation at the beginning or end of the session, as well as changing the word visualize to imagine. The word imagine frees them to use the rest of their senses to create the feeling you’re likely expecting. Bonus: For your strong-minded neurotypical clients who hate being told what to do, both alternatives give them choice and agency, which will help them relax into the experience. 

What You Can Do

There are easy accommodations you can make for anyone who has visual sensitivities or processing issues.

• Sunglasses. If a client chooses to wearsunglasses in the waiting area or other nontreatment-related spaces, don’t ask the client why they’re wearing sunglasses. Instead, let them know it’s OK to wear them in the treatment room as well. 

• Eye masks. Invest in and provide either washable or disposable eye masks for your treatment room. Cotton rounds are a relatively inexpensive alternative to disposable eye masks: simply place one on each eye while your client is supine. Your neurotypical clients who want to be massaged in cave-like darkness will love you for this. Just make sure you read the section on tactile sensitivities before purchasing a set of eye masks, especially disposable ones, for your clients. You don’t want to alleviate the light sensitivity by triggering a tactile one. Alternatively, you could let them bring one from home to use in your office.

• Keep lighting levels as low as is safe. Eliminate bright or fluorescent lighting. If you can’t eliminate it, provide an alternate, low-wattage light source. 

• Be intentional and consent-seeking if you do any type of guided imagery with clients. Ask if they’d like to do a guided visualization or meditation. If they’re open to it, ask them to imagine the scene rather than visualize it. 

• Use at least a 12-point font in your client communications. This applies to both printed and web-based text.

• Use bullet points. Many people, both neurodivergent and neurotypical, have difficulty reading long blocks of text. 

• Use dyslexic-friendly fonts wherever and whenever you can.³

Auditory 

Many neurodivergent people have auditory processing disorder (APD). There are five types of APD,⁴ and it’s common for neurodivergent people with APD to have more than one type. 

The symptoms of APD can manifest in many ways, but the following are the ones you’re likely to encounter in your office:

• Difficulty discriminating one sound from another, including differentiating background noise (including white noise) from conversation

• A delay from hearing the words to the time the words make sense to the brain. This results in asking others to repeat themselves but then responding appropriately partway through that repetition, or asking others to repeat themselves multiple times and still not fully understanding what was said

• Recalling information out of order. This results in skipping around when recounting things, such as when and how their pain began, when and how it manifests, or how it’s made better or worse

• Difficulty expressing themselves clearly 

• Having their train of thought derail in the middle of speaking

• Difficulty with speech that’s spoken more rapidly than they typically speak

• Difficulty understanding accents 

• Confusing words that are similar 

• Mispronouncing words

• A hypersensitivity to sounds in general, making some “normal” volumes and pitches painful

It’s important to note that some neurodivergent conditions involve brains that need lots of stimulation (like ADHD). Others find certain tempos, pitches, tones, or complexities frustrating at best and painful at worst. Highly stressed neurotypical clients can also find very slow music that’s completely out of sync with their mood more annoying than relaxing. 

It’s important to consider the noises in your entire office, not just the treatment room. Traffic noise, phone conversations, noise from the business next door, fans, and filters can make hearing or understanding difficult for those with auditory processing disorder. They can also interfere with your older clients’ ability to distinguish your words from the background noise. 

What You Can Do 

• Be patient and understanding. If a client asks you to repeat yourself often, they’re at least as frustrated as you are, probably more so because they have to deal with it in every conversation.

• Be mindful of sound levels everywhere in your office, not just the treatment room. Post signs asking everyone to silence their cell phones and to step outside to take a phone call. Note: If you share a waiting area with other businesses, like I do, check with the other businesses to see if they’re OK with such signage.

• Allow clients to bring and wear their own noise-canceling headphones, earbuds, or earplugs if they need to. Many noises are beyond our ability to control so encourage clients to bring what makes them most comfortable to the session.

• Have at least one alternate playlist available even if it’s just one album on repeat. The best playlists to have on hand include songs that are a bit more up-tempo, or songs that are less complex, such as having only one or two instruments or no time/tempo changes. You can also allow clients to bring their favorite playlist.

Scent and Taste 

The amount of a scent that someone finds pleasing varies from one person to another, and what one person considers pleasing, another may find repellent. While this is by no means exclusive to neurodivergent people, they do tend to have more hypersensitivities. The big things to watch out for here are essential oils, scented candles, scented cleaners, laundry detergents, and perfume. 

How does taste factor into a massage office? If you’ve ever tasted someone’s perfume, especially if they were gone but their vapor trail remained, you understand how scent and taste are inextricably linked. People with hypersensitivities to scent will often taste a scent at a much lower level than the rest of us. For this reason, having good ventilation and being mindful of scents in your office is important. This will also help your neurotypical clients with multiple chemical sensitivities or allergies.

If your practice is heavily dependent on the use of essential oils, someone with olfactory, taste, or multiple chemical sensitivities may not be a good fit for your practice.

What You Can Do 

• Have a no-perfume policy in your office. While you can’t prevent someone from wearing a scent in, you can ask clients to wait until they leave your office before applying/reapplying their perfume.

• Use unscented cleaners. This is especially important if you don’t have a lot of time between clients and don’t run a HEPA air filter in your office/treatment room.

• Only use a small amount of an essential oil on clients. Once you’ve received the client’s consent, 1–2 well-diluted drops of essential oil are all you should need in any given area. With essential oils, less is more anyway. Bonus: You also minimize the risk of skin irritation.

• Do not use scented detergent or fabric softener on your towels or sheets. Your clients with multiple chemical sensitivities or allergies will also thank you. Remember, there is no scent that’s universally loved, not even lavender or peppermint. 

• Avoid scented candles and essential oil diffusers in your office. If your practice is heavily dependent on the use of scents, clearly state that on your website and marketing materials so prospective clients may self-select in or out of scheduling, as appropriate for their needs.

• Make sure to have proper ventilation, such as a HEPA air filter or window that can be opened. If you use essential oils, make sure to air out the room between clients.

Tactile Issues and Temperature

Many neurodivergent people have extreme sensitivities to textures. A bad texture can cause many sensations, from discomfort to intense physical pain. Unfortunately, there’s no definitive list of good versus bad fabrics because a texture that causes one neurodivergent person physical pain could cause another to experience sensory euphoria. Generally, soft, natural fabrics are the way to go. That said, sherpa blankets, while toasty warm, are very much a love-it (soft) or hate-it (scratchy or tickly) item. I’m not telling you what to use in your office. I only ask that you be aware and, if possible, have an alternative available. 

Tactile hypersensitivity isn’t limited to fabric; it also includes anything clients may lie on while on your table. Things like bolster straps, fabric creases, and loose strings on your linens are easy to minimize. For instance, if you have arm bolsters that are held on with elastic and don’t have a lambswool or other type of pad on the bolsters, consider getting one.

Another hallmark of several neurodivergent conditions is having difficulty regulating body temperature. Some people overheat easily, at temperatures we might normally think of as comfortable. Others will wear a winter coat at the same temperature. Here again, options are the best accommodations. 

I’m going to include pressure needs here as well. As we learned in massage school, light touch is exciting to the nervous system and firm, even pressure is calming. This is especially true for many neurodivergent people. Some have a hyperactive, hypersensitive nervous system, and light touch can literally make them want to jump out of their skin. This means it’s more important than ever to use firm, even pressure to calm their nervous system because light, pokey, or painful pressure will dysregulate them. If you think of the pressure of a warm, comforting hug, you’re on the right track. Neurotypical clients also have fabric, pressure, and temperature preferences, but generally not to the extremes that neurodivergent people do.

What You Can Do 

• Use soft, fluffy fabrics as much as possible. Your neurotypical clients will also love the feel of soft, fluffy, fringe-free fabrics.

• Have an alternate blanket available. If you normally use sherpa blankets on your table, have one blanket available as an alternate, non-stabby, non-tickly fabric.

• Avoid blankets and throws with fringe. And don’t forget to trim loose strings on your sheets and blankets. 

• Have a table warmer with multiple settings. Add bonus points if it’s easily accessible and adjustable mid-session.

• Have an electric blanket available for your perpetually cold clients. Put it in a duvet cover for easy cleaning. Boss-level hack: Use your electric blanket and table warmer together. Your perpetually cold clients will appreciate you. 

• A space heater is your friend. If you share a thermostat with other businesses, and your lease allows, have a space heater available for additional warmth in your office.

• A portable fan is also your friend. A must-have if you don’t have a window that opens and don’t have control of the thermostat. Add bonus points if it has an adjustable height. Your peri- and postmenopausal clients will thank you for this as well. Note: Some neurodivergent people loathe the feel of wind or air on their face (or in general), so check in with your clients about fan height and placement.

• Minimize a Princess and the Pea-type situation. Be mindful of, and reduce, the number of things clients may be lying on top of while getting a massage. 

• Apply broad, even pressure with your whole palm. Seriously calming—enough said.

• Have a weighted blanket or alternative available. If the weighted blanket doesn’t come with a removable/washable cover, put it in a duvet cover. Alternatively, you can offer extra blankets or a yoga blanket (or two) for weight. Bonus: They’re cheaper and easier to wash than a weighted blanket.

Proprioception, Interoception, and Masking

There’s not a lot we can do for our clients with proprioceptive and interoceptive differences, aside from being understanding, leaving our assumptions and judgments outside the treatment room, and offering a few dignity-saving accommodations. A fair number of neurodivergent people are hypersensitive and/or hyposensitive to internal body sensations. They may have difficulty knowing when they’re hot, cold, hungry, thirsty, need to use the bathroom, and/or have trouble regulating their body temperature.

Another way this can manifest is knowing something’s wrong with their body, but not being able to put their finger on exactly what or where the problem is. Depending on the specific handful of Skittles they have, they may also have difficulty describing the sensations they feel. This is often perceived by those who don’t understand interoceptive issues as hypochondria. If a client has a vague complaint, instead of dismissing it, channel your curiosity and talk to them about it. 

Depending on the complaint, you may want to ask your client if they’d like you to avoid an area or spend extra time on an area. Bring your mystery-solving, investigative A game to their complaint and you could earn their trust fairly quickly by being the one person who finally believes them. Whether you can physically help them or not, they will appreciate and respect you for taking them seriously. It can be easy to forget that our clients know themselves a lot better than we do, even if they can’t express it as well as they (and you) would like. 

One way interoceptive issues can manifest in a massage setting is with a sudden, urgent need to go to the bathroom. Many neurodivergent people are unaware they need to use the restroom until it’s urgent. Sometimes they can only feel the urge in certain body positions or when changing positions. They may sit in your waiting area completely unaware they have a full bladder until they stand up and have an urgent need to go. Or they may feel an urgent need as soon as they roll over to a new position. Either way, giving them the grace to make a quick pit stop before the session or a dignity-preserving trip to the restroom mid-session is the best thing you can do. Your neurotypical clients with pelvic floor dysfunction will also benefit from your understanding and accommodations.

Some neurodivergent people also have proprioceptive issues. They can be clumsy and/or have lots of bruises from walking into things or opening their car door into their own face (or maybe that one’s just me). If they’re not good at camouflaging their proprioceptive issues, they may even walk like they’re slightly drunk. If they are good at camouflaging, they’ll likely be carrying a lot of tension in their leg, hip, and low-back muscles from forcing themselves to walk “normally.” Don’t try to “dig all the tension out” because that won’t happen. If by some miracle you do manage, you may be compromising their ability to camouflage after the session. That could be dangerous for them, depending on where they need to go or what they need to do afterward. When it comes to relieving the tension from this type of camouflaging, slow and steady wins the race.

Another source of muscle tension is “masking” or suppressing needs or behaviors that others find “weird.” It can also involve mimicking behaviors of others in an attempt to fit in. Each time you see a client who masks or camouflages a lot, their starting muscle tension for each session will likely be as high as it was at the beginning of their first session. Don’t let this discourage you. As their trust in you grows, they’ll be able to relax more on the table. They may never get to a level that you’d consider relaxed, but they don’t need to. Just let them float out of your office more relaxed than they’ve ever been.

What You Can Do

• Be patient and understanding. Leave your judgmental sentiments behind and use your empathy. Treat your clients how you would want to be treated. 

• Have a robe or other easy covering for clients to use. In case they need to use the restroom urgently mid-session, a robe is important. When it’s urgent, putting pants on is almost impossible without having an accident.

• Believe your clients when they say they’re relaxed. “Relaxed” is a subjective state, and therefore different for each person. If your client says they’re relaxed, believe them.  

This is in no way a comprehensive list of neurodivergent traits or accommodations, but it’s a good place to start. Remember, no one expects you to make all the possible accommodations I’ve mentioned, especially if they’re counter to your needs. Heck, no one’s saying you have to make any at all, but some are quite easy and cost zero money—like believing your clients when they say they’re relaxed. 

If you want to better serve your neurodivergent, and many neurotypical, clients, I encourage you to evaluate yourself and your practice honestly and decide where you could make the greatest improvement. Then, choose a couple accommodations you can easily and quickly implement and put them in place. Later, choose a couple more as goals that you’ll work on and implement those. In no time, you’ll have a neurodivergent-friendly practice. And given that a great many neurodivergent people don’t like change, if you can meet their needs, you’ll have some of the most loyal clients you’ve ever had. 

Notes

1. NIH National Cancer Institute Division of Cancer Epidemiology & Genetics, “Neurodiversity,” April 25, 2022, https://dceg.cancer.gov/about/diversity-inclusion/inclusivity-minute/2022/neurodiversity.

2. Cleveland Clinic, “Neurodivergent,” last reviewed June 2, 2022, https://my.clevelandclinic.org/health/symptoms/23154-neurodivergent.

3. British Dyslexia Association, “Creating a Dyslexia Friendly Workplace,” accessed March 2023, https://bdadyslexia.org.uk/advice/employers/creating-a-dyslexia-friendly-workplace/dyslexia-friendly-style-guide; Exceptional Individuals, “Dyslexia Fonts: The Top 10 Dyslexia Friendly Styles,” November 10, 2020, www.exceptionalindividuals.com/about-us/blog/our-top-10-dyslexia-friendly-fonts.

4. Vocovision, “Auditory Processing Disorder (APD): Symptoms, Testing & Treatment,” accessed March 2023, www.vocovision.com/resources/parents/auditory-processing-disorder.

“Why do we need labels? I treat everyone as an individual.”

Labels are very important, especially for late-diagnosed individuals (i.e., those diagnosed as adults).

First, someone’s neurodivergence isn’t simply a piece of who they are . . . it’s literally the way their brain processes the world. It is who they are. To deny the importance of their label(s) is to not only deny their experience, but to also deny the wholeness of their humanity. 

A diagnosis/label is often the first time they can give themselves some grace when they struggle with “easy” things. You may see them as perfectly “normal” (whatever that is), albeit a little quirky. What you don’t see is the incredible amount of energy they expend as they attempt to act in a way that neurotypical people expect. 

A label also normalizes neurodivergence and makes it easier to ask for, and receive, the accommodations they may need. 

Most Common Neurodivergent Conditions

Apraxia/dyspraxia

Attention deficit hyperactivity disorder (ADHD)

Autism

Dyscalculia (difficulty with math)

Dysgraphia (difficulty writing)

Dyslexia

Obsessive-compulsive disorder

Social anxiety (only this specific type of anxiety)

Sensory processing disorders

Tourette’s syndrome

Get Ahead of the Sensory Issue

You won’t be able to tell if someone has a sensory sensitivity just by looking at them, so it’s important to ask. Some simple additions to your health history or intake form will be immeasurably helpful for all your clients. Then, follow up or clarify their answers in your verbal intake:

• Are you sensitive to light?

• Are you sensitive to sounds?

• Are you sensitive to smells?

• Do you get hot easily or have trouble cooling down?

• Do you get cold easily or have trouble warming up?

• Do you have an aversion to xyz fabrics [name your regular sheet and blanket fabrics]?

• Do you have an aversion to xyz fabrics [name your alternate sheet and blanket fabrics]?

• Do you have an aversion to being touched on any of the following: scalp, face, neck, back, arm, hand, leg, foot?

• What kind of pressure do you prefer? Light, medium/firm, deep, unsure, this is my first massage/haven’t experienced a pressure I
really like.

How can someone be both sensory avoidant and sensory seeking?

While it may seem like an impossible contradiction, it’s actually quite normal. We have five senses, but they don’t all function the same in any given person. For instance, someone may have a visual impairment but be hypersensitive to sound or have a hearing impairment but be extremely sensitive to tactile information. Different sense, different sensitivity. 

Self-Diagnosis Is Valid 

Never ask someone whether they have been officially diagnosed with a specific neurodivergence. The neurodivergent population recognizes self-realization/self-diagnosis as valid because:

1. Criteria have changed drastically since the lost generation (elder millennials and older) were young.

2. Criteria for most diagnoses are based on straight, White, middle- and upper-class boys.

3. Our health-care system, especially health insurance, doesn’t prioritize mental or neurodevelopmental health.

4. Formal assessments are very expensive, can have a years-long waiting list, and may not be available within a reasonable travel distance in many places. 

Requiring a formal diagnosis to give someone the accommodations they need is considered ableist and classist.