negotiations with a nervous system: Life as a PDA Therapist

This guest post comes from our very own Rainn Stone, LICSW, TTGC (They/Them), who brought their expertise, lived experience, and insight to Dr. Neff’s Free Neurodivergent Suicide Prevention Resource. Their contribution helps make this guide practical, deeply affirming, and grounded in the kind of understanding we all need. Click to access your free copy of Help Me Stay.
For more information on Rainn: Rainny Days Counseling & Coaching.

There is a particular irony in being a therapist whose nervous system experiences existence itself as a demand. I specialize in autonomy. I teach consent, choice, regulation. I help children who have been misunderstood lean into themselves.

And still —

my body flinches at any perceived loss of autonomy 

The Demand That Isn’t Visible

Pathological Demand Avoidance — or Persistent Drive for Autonomy, depending on who you ask — is often described behaviorally.

Refusal.
Deflection.
Procrastination.
Meltdowns.

What is less often named is this:
It is not the task.
It is the nervous system registering threat.

For me, the threat isn’t “do the dishes.”
It is: You must. You have to. You should be able to. People are counting on you.

When you are a chronically ill, AuDHD therapist, life is structured around obligations that are not optional.

Medication schedules.
Medical appointments.
Documentation deadlines.
Client sessions at 4pm whether your heart rate is 140 or not.
The world calls that responsibility. My nervous system calls it captivity.

Chronic Illness as Perpetual Demand

Chronic illness adds a layer most PDA discourse does not address.

Hydrate.
Salt.
Compression.
Track symptoms.
Pace.
Rest.
Don’t overdo it.
But don’t decondition.
But don’t cancel too much.
But don’t disappoint anyone.

Every intervention meant to “help” becomes another instruction.
And PDA does not differentiate between a helpful suggestion and a coercive system. Both feel like loss of choice.

Clinically, we understand that individuals with PDA profiles often have a heightened threat response to perceived control. The amygdala fires not because the demand is large, but because autonomy feels compromised.

Now add a body that collapses if you do not comply with certain demands.

I cannot simply opt out of hydration because it feels oppressive, but my nervous system still resists the command.

So I negotiate with myself all day.
Not because I am lazy.
Not because I lack discipline.
Because my brain equates obligation with danger.

Being the Therapist Who Cannot “Just Do It”

There is a specific shame in being the clinician who teaches executive functioning skills while privately bargaining with herself to send an email.
I can map polyvagal states.
I can conceptualize trauma adaptations.
I can explain the interplay of dopamine regulation and demand sensitivity.

And still:
The note sits.
The laundry waits.
The administrative portal feels like a wall.

In PDA, avoidance is not avoidance of effort. It is avoidance of felt coercion.

Even self-generated goals can trigger it.

“Write the article.” “Finish the slides.” “Prepare the training.”

The moment it becomes an internal demand, my body stiffens.

This is the clinical paradox: High insight does not override nervous system activation.

The Mask of Competence

Many PDA adults — especially those socialized to be competent, high-achieving, or caretaking — develop adaptive personas.

Charm. Humor. Intellectualization. Hyper-capability.

I built systems out of survival. Spreadsheets out of hurricanes. Checklists out of chaos.

But here’s the interplay clinicians rarely name: Sometimes structure soothes. Sometimes structure suffocates.
The difference is autonomy.

If I choose the checklist, it regulates me. If the checklist is prescribed, it becomes a cage.

As a therapist, I have to be exquisitely careful not to replicate the very dynamic my nervous system resists.

“Let’s make a plan” can feel supportive — or suffocating — depending on how it lands.

I know this not theoretically. I know it somatically.

Demand Avoidance in the Therapy Room

Here is the quiet truth: PDA has made me a better clinician.

I do not force eye contact.
I do not insist on compliance.
I do not confuse distress with defiance.

When a child says no, I believe the no.
Because I know what it feels like when your body says no and the world says override it.

My chronic illness has also shaped my practice.
I pace sessions because I must pace life.
I build flexibility into policies because rigidity harms nervous systems like mine.
I understand flare days not as moral failures but as physiological realities.

This is not lack of professionalism. It is embodied ethics.

The Internalized Ableism

There is grief here too.

The part of me that still believes I should be able to “just push through.”
The capitalist ghost whispering productivity equals worth.
The clinician who feels fraudulent when rescheduling due to tachycardia.

PDA amplifies shame in environments built on compliance.
Chronic illness amplifies dependence in cultures that worship independence.
AudHD amplifies sensory and cognitive load in systems that reward linear processing.

And yet —

I am here.
Licensed. Trusted. Holding others.
Not in spite of these identities. But informed by them.

Reframing the Narrative

Clinically, PDA is often pathologized. But what if we reframe it as an extreme sensitivity to autonomy violation?
What if chronic illness is not weakness but an enforced intimacy with limitation?
What if being an AudHD therapist is not hypocrisy but a living laboratory of nervous system awareness?

My life is a constant negotiation between:
Responsibility and rebellion.
Structure and spaciousness.
Care for others and care for my body.

I do not “overcome” PDA. I collaborate with it.

I reduce perceived demands.
I build choice into everything.
I language-shift from “have to” to “get to” or “choose to.”
I externalize systems so they feel less like internal tyrants.

Sometimes I still melt down.
Sometimes I still avoid.
Sometimes I sit on the floor of my office and let my heart rate settle before seeing the next client.

And then I go in.
Not as someone who conquered their nervous system. But as someone who knows it.

The Demand to Live

The greatest demand is not email.
Not documentation.
Not hydration.

It is this:
Stay.
Show up.
Keep participating in a world that often misunderstands you.

PDA resists coercion.
Chronic illness resists fantasy.
AudHD resists conformity.
And yet I remain.

Not compliant.
Not cured.
Not optimized.

But choosing, again and again, to practice in a way that honors autonomy — mine and my clients’.

If that is demand avoidance, then perhaps what I am avoiding is not responsibility —but erasure.

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