Who is the “perfect” candidate for therapy? Does such a thing even exist? A persistent misconception held not only by the general public but also within the mental health provider community as well, is the belief that some individuals cannot access or benefit from therapy because they are unable to “cognitively keep up.” This belief reflects a long-standing and systemic form of gatekeeping that has affected the disabled community for decades. It extends beyond mental health care and into nearly every other area of service provision. Time and again, people with disabilities have been pushed to the margins of society, a reality rooted in a long history of oppression and inequity. Addressing this requires a meaningful shift within the mental health field—one that prioritizes accessibility and affirms that individuals with disabilities deserve equitable access to therapeutic care.
As a long-time special educator and later a mental health provider within the school system, I have been continually struck by how often I encounter assumptions that students with cognitive disabilities are unable to access or benefit from therapy. Ask any therapist what they are taught early on about positive client outcomes, and the answer is almost always the same: the therapeutic relationship outweighs any specific intervention or modality. This principle has been repeatedly supported by outcomes research and is often referred to as the “golden rule” in counseling and social work education. If relationship truly is the strongest predictor of therapeutic success, how can we simultaneously claim that certain groups are incapable of benefiting from supportive, nonjudgmental relationships? As humans, we all share a fundamental need for belonging. No factor, including cognitive ability, eliminates this basic human need. In fact, I would argue that individuals with disabilities may benefit the most from therapeutic relationships, as they are often socially excluded, denied agency, and placed in roles that reinforce power imbalances and limited autonomy.
While I could delve into the long and inequitable histories that have shaped and continue to shape the experiences of this community, I instead want to focus on how therapeutic intervention can and does improve the lives of individuals with cognitive disabilities in ways that are comparable to those without disabilities. Before getting into this, It is also important to acknowledge a common experience within this population: Service Overload or flooding. These multitude of services thrown at individuals with disabilities often emphasize behavioral modification and are rooted in a medical model that prioritizes symptom identification and reduction. Neuroaffirming therapeutic approaches differ fundamentally. Rather than focusing on suppression or societal normalization, they view the individual holistically and prioritize empowerment, acceptance, and compassionate self-understanding. One approach communicates, “You are different—how do we make you fit in?” The other asks, “You are you—how do we honor that in a world not designed with you in mind?” I am not suggesting that services rooted in the medical model are unnecessary; I have personally witnessed meaningful growth and significant improvements in clients’ lives as a result of these interventions. Rather, I am advocating for broader access to a holistic range of supports that include empowering, relationship-based interventions in which the client is positioned as the expert in their own experience, rather than as a passive recipient of information.
Over my more than ten years working in educational and therapeutic settings, particularly with individuals with moderate to severe cognitive disabilities including: intellectual disabilities, Down syndrome, fetal alcohol spectrum disorders—I have directly witnessed the power of the therapeutic alliance. While these individuals face immense challenges in systems not built to accommodate them, most services focus solely on helping them function within existing structures. There is little attention paid to dismantling systemic barriers or addressing universal human experiences such as puberty, relationship challenges, grief, and loss to name a few. These are areas where many young people receive support through peers, therapy, athletic coaches, or mentors—support that is often inaccessible to or withheld from individuals with more severe disabilities. Too often, society forgets that they experience the same everyday challenges: arguments with parents, romantic rejection, sexual curiosity, and disappointment. At the same time, they face additional barriers, including the ongoing struggle to claim independence in a world that frequently communicates that they do not belong.
Now imagine these young people having access to a relationship that challenges these assumptions. A space where they can show up as they are without constant correction or “reality checks”, and instead explore possibilities. A space where strengths are emphasized, barriers are questioned, and oppressive power dynamics are intentionally dismantled. In this space, individuals who are rarely seen as experts in their own lives are given autonomy and agency. I have witnessed this transformation time and again in therapeutic settings: young people with limited self-belief growing into individuals who begin to envision and often achieve milestones they once believed were unattainable. These outcomes mirror what clinicians strive for across all populations and reinforce what research consistently shows: when a strong therapeutic relationship exists and a client is willing to engage, meaningful change is possible.
So if relationship is the most critical factor in therapeutic success, why are we still gatekeeping access to these relationships for individuals with cognitive disabilities? Like any major systemic shift, change takes time. Psychiatry and psychotherapy are relatively young fields, and individuals with disabilities have historically been among the last considered. This is largely due to longstanding medical ideologies that falsely positioned this population as incapable of growth or development, labeling them “a lost cause” and justifying their segregation from society. Although deinstitutionalization marked a significant step toward integration, the legacy of separation remains deeply ingrained. We continue to confront these beliefs daily as we advocate for more inclusive systems, laws, and societal structures. In short, real systemic change takes time and intentional effort, and when certain groups have been left behind from the start, the climb to equity is that much steeper.
To close, I leave you where we started and with an image. Who is the perfect candidate for therapy and is there even such a thing? Imagine two young people sitting on a bench, both crying after being rejected by a crush. One is offered a steady hand and compassionate validation meeting them where they are. The other is handed an instructional manual explaining how to return to baseline functioning and reduce maladaptive responses to rejection. Which would you choose for yourself or for your child?