Unmasking PDA Series: Part 5: Working Therapeutically with Adults with a Pathological Demand Avoidance (PDA) Profile
Pathological Demand Avoidance—commonly referred to as PDA—continues to gain recognition as an important but misunderstood profile for Autistic adults. Currently, it is spoken about more in the context of children, however many adult PDAers* are now discovering and identifying with this profile. Often this is after learning about their child’s PDA profile and recognition of similar experiences. By this stage, many adults have often had years of feeling overwhelmed, misdiagnosed, or invalidated. Read more about lived experiences of adult PDAers here:
Part One: Could This Be Me? Recognising PDA in Adulthood
Part Two: Making Sense of Needs and Supports
Part Three: Studying on Your Terms - University Life as a PDAer
Part Four: PDA, Partnership and Parenting - Navigating the Demands of Family Life
As clinicians that have worked with many PDA adults and listened to the often challenging experiences of our lived experience community, we frequently ask ourselves, “How can we, as health professionals, work more supportively with our adult PDA clients in a way that they need?”
Here is some of what we have learned so far about creating a space that feels safe, respectful, and empowering.
What Is PDA?
PDA is best understood as an anxiety-driven need to avoid everyday demands, often leading to intense resistance—even to things the person might want to do. While others may describe or experience this behaviour as challenging, difficult and intentional/manipulative, the patterns of internalised and observable behaviours are understood to be a nervous system response to perceived threats to a deep need for control and autonomy.
In adults, this might look like:
Avoiding work tasks, even important ones
Missing appointments (including therapy sessions)
Struggling to meet personal goals
Fluctuating between intense social engagement and withdrawal
Feeling misunderstood or mislabelled as "difficult" or "lazy"
Many adults with PDA have spent years masking their struggles leading to burnout, exhaustion, and a lack of identity.
Working with PDAers in Therapy
Adult PDAers are often extremely perceptive and sensitive to power dynamics. Our clients require a sense of autonomy and control and we understand that the therapeutic relationship comes with an inbuilt power difference. A sense of safety is crucial to building a strong rapport and providing the client with some opportunities to restore equity and defuse the power differential. Imagine, if you can, a lifetime of invalidating environments, even in past therapeutic relationships. It takes time, patience, predictability and allowing the client to lead/direct to create a safe therapeutic alliance.
A PDAer may appear resistant, however understanding PDA means understanding that this is not non-compliance in therapy. The avoidance of topics or appearance of disengagement is instead an indicator of anxiety or nervous system activation, a lack of felt safety, an unequal relationship and a lack of control. It can feel too hard, too overwhelming and the brain may be screaming, “too much”. A good therapeutic approach and framework helps to work with that anxiety and to provide a strong, supportive environment for the client. The therapist will also need to be flexible in their approaches and not take things personally (this is crucial!)
Below are some ideas that might support a strong therapeutic relationship and meaningful outcomes; however, remember that everyone is different, and you must get to know your client deeply and what their preferences are:
Partnership and collaboration: For PDAers, even gentle directives and perceived agendas can feel threatening. Set up a collaborative therapeutic relationship from the start that values the client’s input, opinions, and previous experiences of what has and hasn’t worked; be curious about their needs and continue to check in with them along the way.
Use metaphor and storytelling: learn your client’s individual communication style and preferences. In contrast to more literal communication approaches with Autistic clients generally, PDAers may respond well to other indirect ways of eliciting and describing their personal narratives. While some Autistic clients may struggle with metaphors, for some PDAers these may act as a form of depersonalisation and elicit more engagement in a therapeutic topic.
Allow flexibility: Let them shape the structure and pacing of sessions. Be attuned to their nervous system states and be prepared to pivot when there isn’t a good fit between therapeutic process and client needs.
Incorporate humour and playfulness: This can help build rapport. Our clients are some of the funniest people we know, and we feel privileged when they share their humour with us.
Celebrate autonomy: Create a casual space free of power imbalance and expectations as much as possible within the therapy room. PDAers have a right to say no and should be validated in this.
Explore identity: Many adult PDAers have struggled to understand their own identity. Help them explore it safely. Knowing themselves can be rewarding and healing. Click here for more information about exploring neurotypes.
Listen to lived experience: In our clinical experience, PDAers are highly intelligent people with capacity for depth and breadth of knowledge. For example, they can be well-versed in topics relating to their physical and mental health care. Take time to listen and understand, work collaboratively and partner them in their health care journey.
Manage your own nervous system: being attuned to your own nervous system responses can help mitigate dysregulation for yourself and your client, and also facilitate co-regulation of your client’s nervous system.
*PDAer refers to a person with a PDA profile
References
PDA Society: A UK-based organisation offering resources for PDAers and professionals
PDA by PDAers: From Anxiety to Avoidance and Masking to Meltdowns (Sally Cat, 2018)
