When disability gets
misread as psychology.
Sometimes the problem is not hidden beneath the explanation you gave.
Psychotherapy is built around meaning. Therapists are trained to notice patterns, avoidance, defences, relationships, emotions, unconscious processes and the meanings people make of their experience. That can be enormously useful. But it creates a particular risk when disability enters the room.
Sometimes a person gives a perfectly accurate explanation of what their body needs, and therapy goes looking for a deeper psychological one. Fatigue becomes avoidance. Needing help becomes dependency. A physical limit becomes inhibition. Anger about discrimination becomes dysregulation. An inaccessible intervention becomes resistance.
The question isn’t whether psychology matters. It’s: are we adding psychological understanding, or replacing somebody’s reality with it?
Maybe this
has happened to you.
Something physical keeps being made psychological.
I’m exhausted, and tired of having the exhaustion interpreted
“Sometimes I genuinely cannot do more. I don’t know how to say that without sounding as though I’m giving up.”
I’m starting to doubt myself
“After being questioned enough times, I don’t know whether to trust my own explanation anymore.”
I don’t know whether this is physical or psychological
“Maybe both are involved. I just don’t want one explanation to erase the other.”
I’m angry about being misunderstood
“I’m tired of having to prove that I know something about my own body.”
My therapist got this wrong
“Can therapy recover when an interpretation didn’t fit?”
I’m a therapist worried I’m over-interpreting
“How do I stay psychologically curious without making everything psychological?”
The pattern
underneath the pattern.
A client says “I can’t do that.” The therapist hears “something is stopping you.” That may be true. But those sentences aren’t identical.
“I can’t” might mean fear. It might also mean: my joints will dislocate. I cannot transfer safely. My energy is gone. The lights are overwhelming me. My medication is affecting me. My wheelchair physically will not fit there. Or: I can do it once, but I’ll pay for it for the rest of the day.
Psychotherapy becomes less accurate when it assumes the psychological explanation is automatically deeper than the person’s stated one. Sometimes the stated explanation is already the important one.
Before interpreting, a quick check.
Eight common misreadings in brief. Each may sometimes be psychological too; the point is to ask before deciding. The full explanation of each follows below.
| What the therapist sees | What else could be happening | What to ask first | Go further |
|---|---|---|---|
| Cancelling, doing less, leaving early | Fatigue, pain, medication, poor sleep, or the effort of getting through inaccessible places | “How much energy did this take, and what did it cost afterwards?” | Fatigue or Avoidance? |
| Not joining in with an exercise | The body can’t comfortably stand, lie down, move, breathe or hold eye contact that way | “Is this physically possible for you, comfortably?” | Adapting Therapeutic Methods |
| Needing physical help | Ordinary support, which says nothing on its own about maturity or autonomy | “Who decides how this help is given?” | Dependency, Interdependence and Care |
| Worry about access, transport or health | An accurate reading based on what has happened before | “What has happened before in situations like this?” | When “Distortions” Are Actually Reality |
| Anger | A fitting response to discrimination, poor care or being underestimated | “What happened?” | Clinical Ableism |
| Long silences | Processing time, fatigue, pain, word-finding, sensory overload, or deciding whether it’s safe to say | “Would more time, or another way of answering, help?” | Power, Access and the Therapy Frame |
| Rocking, posture, looking away | Muscle tone, neurology, pain, or how this body regulates itself | “Is this something your body usually does?” | Meaning Is Not Cause |
| Not attending | Transport, building access, session length, personal assistance or cost | “What would make it possible to come?” | Access Barriers to Psychotherapy |
Eight ways disability
can be misread.
Fatigue becomes avoidance
“I don’t have the energy” meets “what are you avoiding?” Sometimes avoidance really is present. But fatigue can also be fatigue. Pain, sleep disruption, medication, chronic illness, neurological difference and the sheer labour of navigating inaccessible environments can all affect capacity.
Before looking underneath the fatigue: believe that the fatigue may exist.
Physical limitation becomes psychological inhibition
A body doesn’t perform an exercise. “What’s holding you back?” is useful if the body can physically do the task. Less useful if the exercise requires standing, lying on the floor, sustained eye contact, a particular breathing pattern, large movement, or physical endurance not available.
Sometimes the person is inhibited. Sometimes the method is inaccessible.
Assistance becomes dependency
A person needs physical help. Therapy begins wondering about dependency, separation, autonomy, or regression. Those may occasionally be relevant. But requiring assistance doesn’t automatically indicate anything about psychological maturity. Someone can require extensive physical support and exercise considerable autonomy.
The more useful question: how much choice and control does this person have within the support they need?
Realistic fear becomes anxiety distortion
A disabled person worries transport may fail, their body may deteriorate, a venue may be inaccessible, a healthcare professional may not listen, or somebody may refuse an accommodation. Sometimes anxiety exaggerates risk. Sometimes previous experience makes the fear entirely understandable.
Therapy has to distinguish “my mind is telling me something unlikely will happen” from “this has happened repeatedly and I’m preparing for it happening again.”
Anger becomes dysregulation
Fury about being stared at, discrimination, poor healthcare, inaccessible services, being underestimated, or repeatedly having to advocate. Therapy may understandably become interested in regulating the anger.
Before asking “how can we calm this?”, ask “what happened?” Anger can be psychologically complicated and still contain accurate information about injustice.
Silence becomes resistance
Someone takes longer to answer. The therapist experiences the silence as withdrawal, avoidance, defensiveness, or difficulty engaging. But silence may involve processing time, fatigue, communication difference, pain, sensory overload, word-finding difficulty, or deciding whether something feels safe enough to say.
Silence can have meaning. It doesn’t always have the meaning the therapist first imagines.
Movement difference becomes psychological meaning
Rocking, fidgeting, looking away, atypical posture, muscle tone, restricted movement, a different breathing pattern. Body psychotherapy can make us exquisitely attentive to bodily experience. That attention becomes dangerous when “I notice…” quietly becomes “I know what this means.”
A body can contain psychological history. It can also contain impairment, neurology, pain, medication, habit and simple bodily difference.
Non-participation becomes poor motivation
Repeated non-attendance at a group, exercise class, in-person therapy, social event, or healthcare programme can look like disengagement. Until somebody asks: is transport available? Is the building accessible? Can the person tolerate the session length? Is personal assistance available then? Can they afford it? Does the activity assume abilities they don’t have?
Sometimes motivation is the problem. Sometimes participation has been designed around somebody else. Sometimes both are true.
This distinction
matters.
Disability-informed psychotherapy shouldn’t simply reverse the mistake and declare: physical explanations are real, psychological explanations are not. A person can have genuine fatigue and become frightened of activity. They can genuinely need support and feel shame about needing it. A physical limitation can be real and carry enormous grief. A person can be reasonably angry about discrimination and dislike what living in chronic anger is doing to them. A bodily boundary can be necessary and become entangled with older relational experiences.
Taking bodily reality seriously does not mean psychological meaning disappears. The problem is not psychological exploration. The problem is psychological explanation replacing bodily or structural reality before that reality has been understood.
Being misread can
become psychological too.
The original problem may begin outside you. But repeated misreading can eventually affect how you relate to yourself: over-explaining, bringing evidence before anybody asks, rehearsing how to sound believable, minimising symptoms, wondering whether fatigue is “real enough,” questioning whether you’re secretly lazy, forcing yourself beyond your limits, staying quiet because correcting another professional is exhausting, or entering every appointment already preparing to defend your body.
Something can begin as somebody else’s interpretation and eventually become something carried. This is one reason the line between psychological and non-psychological experience cannot always be neatly drawn.
What if I honestly
don’t know?
Sometimes neither therapist nor client knows exactly what’s happening. That’s allowed. Fatigue can have physical and emotional components. Pain affects mood. Anxiety can increase muscular tension. A frightening bodily experience can create anticipatory fear. Depression can reduce activity while disability also limits activity. Trauma can shape somebody’s relationship with a body that also has very real physical limitations.
No need to force certainty. “We don’t know yet” can be a clinically responsible answer. Uncertainty can remain uncertainty while more information is gathered.
Before
interpreting.
A simple order of operations.
Check the body
What is actually being asked of this person’s body? What do they know about pain, fatigue, mobility, sensation, neurology, medication, energy, or capacity? Is anything medically unexplained that needs appropriate healthcare assessment rather than psychotherapy?
Check the environment
Is something about the room, exercise, schedule, technology, communication method, policy, transport, or service creating the difficulty?
Ask the person
What do they think is happening? What have they learned from living in this body? What fits their experience? What doesn’t?
Check the relationship
What’s happening between therapist and client? Is the client becoming guarded? Is the therapist pushing harder? Has trust changed? Is disagreement becoming difficult?
Then consider psychological meaning
There may be rich psychological work here. But let that work add to the picture rather than erase what came before it.
Body. Environment. Person. Relationship. Interpretation.
Take me
into the room.
A therapist invites a client to move from their wheelchair onto the floor for an exercise. The client says: “I can’t get down there safely.” The therapist notices a familiar clinical instinct: I wonder what getting down onto the floor represents. Perhaps vulnerability. Loss of control. Surrender. Dependence.
There may be a fascinating psychological conversation available. But first: can the person physically get onto the floor? If the answer is no, interpreting the limitation before adapting the exercise risks turning the therapist’s inaccessible method into the client’s psychological problem.
The better question: what was the exercise trying to help us explore, and how else could we explore that function in the body you have? The therapeutic goal can remain. The method changes.
In the
therapy room.
I need to sit beside the door because I overheat very quickly.
I wonder whether having the door nearby helps you feel you can escape if things become emotionally intense.
No. I literally overheat and need airflow.
Okay. Thank you. Let’s start there.
There may later be psychological material around safety, bodies or needing the door. Or there may not. Curiosity doesn’t require every observation to become symbolic.
If an interpretation
doesn’t fit.
Noticing is allowed.
Notice the reaction
Something inside might immediately say “no, that’s not what this is.” That reaction is information. It doesn’t automatically prove the therapist is wrong. But it deserves attention.
Separate fact from interpretation
Fact: “I overheat and need airflow.” Interpretation: “you need an escape route when emotional closeness becomes intense.” Those are different statements.
Ask what supports the interpretation
“What makes you think that?” is allowed. Therapy doesn’t have to operate through unexplained professional authority.
Add rather than replace
“There may be something psychological worth exploring around this, but I don’t want the physical explanation replaced by it.” Both can remain available.
Notice what happens next
Can the therapist become curious? Can they reconsider? Can disagreement happen without being treated as defensive? That tells you something important about the therapeutic relationship.
Words
you can use.
Disagreement is not a failure of therapy. Sometimes it’s therapy becoming more accurate.
When the therapist
gets it wrong.
A misinterpretation doesn’t necessarily need to end the therapy. Repair is possible. A therapist might say: “I think I moved too quickly to interpretation. You gave me a concrete explanation of what your body needed, and I treated it as though there must be a deeper psychological reason. I want to reset and understand it from your perspective.”
Repair doesn’t require deciding interpretation is never useful. It requires being able to let go of an interpretation that doesn’t fit. A good therapeutic relationship needs enough flexibility for the therapist to be wrong.
Why does
this happen?
Psychotherapy teaches us to look for meaning
Some traditions pay particular attention to latent meaning, unconscious processes, defence, symbolism, relational repetition, and things not yet explicit. This produces extraordinarily rich work. The difficulty arises when “there may be more here” quietly becomes “your stated explanation cannot be the whole truth.” Sometimes deeper exploration reveals something important. Sometimes the “surface” explanation was accurate.
Therapists have bodies and reactions too
A therapist may feel anxious, protective, helpless, uncomfortable, fascinated, afraid of causing harm, or unsure how to respond to disability. Those reactions may be clinically useful. But a therapist’s bodily or emotional response is not automatically information about the client. It may contain countertransference, personal history, cultural assumptions, ableism, fear, or unfamiliarity. “I feel something strongly” is not the same as “therefore this is true about you.”
The individual becomes the easiest place to locate the problem
Psychotherapy understandably focuses on the individual, which can make it tempting to relocate problems there. The inaccessible service becomes poor engagement. The unrealistic schedule becomes difficulty committing. The discriminatory interaction becomes sensitivity to rejection. The lack of support becomes dependency. Disability-informed practice asks that the surrounding context stay visible.
Who gets
believed?
There’s also a question of authority. Therapists have psychological knowledge. Doctors have medical knowledge. Researchers have specialised knowledge. Those forms of knowledge matter. But disabled people also develop knowledge through living repeatedly in their own bodies and environments. Conflict arises when professional interpretation is automatically treated as more credible than lived knowledge.
That doesn’t mean the client is always correct. It means professional authority shouldn’t make disagreement impossible.
A useful question: whose explanation is currently being treated as the default truth, and why?
A related idea:
diagnostic overshadowing.
In healthcare, diagnostic overshadowing describes situations where symptoms are attributed too quickly to an existing diagnosis instead of being adequately investigated. What’s described on this page overlaps with that idea, but is broader. A psychotherapist doesn’t need to diagnose somebody in order to over-psychologise an experience. It can happen whenever a bodily reality, access issue, or structural problem is given an unnecessary psychological explanation.
Describe before
interpreting.
Clinical notes are one place where assumptions can quietly become “facts.”
“Client appears reluctant to engage fully with floor-based work.”
“Client remained in wheelchair during floor-based exercise and explained that transferring to the floor is not physically safe. Accessible alternative discussed.”
“Client has difficulty tolerating closeness and prefers seating near the door.”
“Client requested seating near the door because overheating requires airflow.” If relational closeness later becomes clinically relevant, record that evidence separately.
“Client has not yet accepted their diagnosis.”
“Client described grief, anger and uncertainty regarding the diagnosis and changes in everyday life.”
“Client demonstrates remarkable resilience despite disability.”
“Client described repeatedly rearranging transport following service cancellations and reported the process as exhausting.”
Describe first. Interpret second. When interpretation is documented, make clear it’s a clinical hypothesis, not an observable fact.
Where should
therapy work?
- The person themselves notices fear, shame or avoidance
- A bodily reality has emotional consequences they want to understand
- Past experience is shaping what happens now
- A relationship pattern continues even when the access issue has been addressed
- Support is wanted with grief, anger, identity or relationships
- Physical reality and psychological meaning are both clearly present
- A concrete bodily explanation hasn’t yet been explored
- There’s an obvious access barrier
- The intervention assumes an ability the person doesn’t have
- Relevant knowledge about the person’s condition is missing
- The client repeatedly says the interpretation doesn’t fit
- A medical concern needs healthcare assessment, or the issue is accommodation, discrimination, resources, policy or environment
Not everything needs therapy. But many things not caused by psychology can still have psychological consequences worth bringing into therapy.
Mine. Yours.
Ours. System.
This framework can help slow the formulation down. Imagine a therapist repeatedly interprets a client’s fatigue as avoidance.
Physical fatigue, fear, shame, depression, past experiences of being disbelieved, or several of these.
Assumptions about motivation, unfamiliarity with fluctuating disability, anxiety about progress, a preferred theoretical explanation. Hypotheses, not facts about the therapist’s inner world.
The client feels disbelieved and says less. The therapist experiences withdrawal and pushes harder. The client becomes more defensive. Trust deteriorates. The interpretation has become part of a relational cycle.
Training that gave little attention to disability. A rigid service model. A cancellation policy incompatible with fluctuating illness. An inaccessible intervention. A culture treating productivity as evidence of wellness.
The difficulty doesn’t have to belong entirely in one place. And what begins in Yours or System may eventually become something the client carries in Mine.
- What exactly did the client tell me? What have I observed directly? What have I inferred?
- Have I checked the bodily explanation? Access and environment?
- What does the client think is happening?
- What assumptions does my theory bring? What kind of body does my intervention assume?
- What would make me change my formulation?
- Am I helping this person understand themselves, or asking them to accept my explanation of them?
- What happened? What was their explanation? What was mine?
- What did their explanation help me understand? What did it leave out?
- Was there a bodily reality that was overlooked? An environmental or access issue?
- Did the disagreement affect the relationship?
- Did I begin doubting something I’d previously known about myself?
- What would I have needed them to ask instead?
The aim is not to ask whether psychology matters. Bodies matter. Relationships matter. Environments matter. Systems matter. A physical reality can develop psychological meaning. A psychological experience can affect the body. All four may be present at once. The goal is not “never interpret disability psychologically.” It’s: do not make psychology the explanation simply because psychology is the tool you have available. Start with the body. Look at the environment. Ask the person. Notice the relationship. Then remain curious about psychological meaning.
Explore
next.
Mine, Yours, Ours, System
A framework for locating psychological, relational and systemic difficulty.
Accessibility & Therapy
When the therapy environment itself becomes part of the problem.
Body Psychotherapy Through a Disability Lens
Working psychologically with the body without assuming every bodily difference has psychological meaning.
Disability & Psychotherapy
Disability theory, psychotherapy and disability-informed formulation.
For Therapists
Clinical reflection, supervision questions and practical disability-informed practice.
Go deeper: Fatigue or Avoidance? takes one of the most common misreadings, exhaustion read as avoidance, through recognising it, telling the two apart together, and repairing the relationship when a therapist gets it wrong.
When something practical is interpreted psychologically
Fatigue, accessibility barriers or physical limitations can sometimes be mistaken for lack of motivation, avoidance or unwillingness. This distinction matters because a psychological intervention cannot remove every practical barrier. Sometimes the most therapeutic response begins with understanding the circumstances.
In the classroom
I learned quite early in life that doing something as simple as sitting in a classroom could involve a bit of multitasking.
When I was younger, I sometimes needed to stretch my legs or attend to my body while also trying to concentrate on what was happening in class.
Now, from the outside, I can imagine that looking a little distracting. Perhaps it didn’t always look like I was giving the lesson my full attention.
But actually, I was trying to do exactly that!
Managing my body wasn’t separate from learning. It was part of what allowed me to learn.
Looking back, I think that’s quite an interesting example of how easily we can misunderstand someone’s behaviour when we don’t understand their circumstances.
What looks like distraction, avoidance or a lack of motivation might actually be someone working incredibly hard to participate.
And sometimes, rather than asking why someone isn’t engaging, we might need to ask what they’re already doing just to be there.
Casey Donaghey is the psychotherapist behind this site and lives with cerebral palsy.
What disabled people have said
Physical symptoms read as psychological
In interviews with 24 adults with physical disabilities about their therapy, some described therapists putting their physical symptoms down to psychological causes. More often, therapists avoided disability or invalidated their experience of it. Participants asked therapists to trust their account of their own body.
Disability assumed to be the cause
In a separate 2024 study of disabled adults in mental healthcare, one of the clearest themes was clinicians wrongly assuming that disability itself was the cause of their mental health difficulties.
Sources
- Conner, K. J., Acosta, V. M., Nouri, R., Tyler von Wrangel, M., Gramillo, E., & Conner, A. (2023). Psychotherapy experiences of U.S. adults with physical disabilities: Recommendations for affirmative practice. The Counseling Psychologist, 51(7), 970–1004. doi:10.1177/00110000231186824
- Wang, K., Ostrove, J. M., Manning, R. B., Fodero, S., Ash, S. L., Whang, J., Bogart, K. R., Cipollina, R., Nario-Redmond, M. R., Adler, J. M., & Lowe, S. R. (2024). Ableism in mental healthcare settings: A qualitative study among U.S. adults with disabilities. SSM – Qualitative Research in Health, 6, 100498. doi:10.1016/j.ssmqr.2024.100498
Summaries are this site’s own wording. Please read the originals.
Through a humanistic lens
- Congruence & Incongruence – when skilled adaptation is mistaken for psychological falseness.
- Gestalt Therapy – when muscle tone gets read as “holding back”.
- Laing, Lived Experience & the False Self – distress that makes sense once you see the situation.
Part of the Humanistic Psychotherapy hub.
The scenarios, quotes, dialogues and case-note rewrites on this page are fictional teaching examples. They draw on patterns that come up often, but none of them describes a real person.
The key ideas on this page come from these sources:
- Diagnostic overshadowing: Reiss, S., Levitan, G. W., & Szyszko, J. (1982). Emotional disturbance and mental retardation: Diagnostic overshadowing. American Journal of Mental Deficiency, 86(6), 567–574. (The title uses the language of its time.)
- Who gets believed: Fricker, M. (2007). Epistemic Injustice: Power and the Ethics of Knowing. Oxford University Press.
- Ableism as a way of seeing: Campbell, F. K. (2009). Contours of Ableism: The Production of Disability and Abledness. Palgrave Macmillan.
- Therapists and disability: Olkin, R. (1999). What Psychotherapists Should Know About Disability. Guilford Press.
For every source cited on the site, see Sources and Bibliography.
- This pattern is common. In interviews with 24 US adults with physical disabilities, about a third said therapists had attributed their physical symptoms to psychological causes, and over half described having their disability experiences invalidated. Conner, K. J., Acosta, V. M., Nouri, R., Tyler von Wrangel, M., Gramillo, E., & Conner, A. (2023). Psychotherapy experiences of U.S. adults with physical disabilities: Recommendations for affirmative practice. The Counseling Psychologist, 51(7), 970–1004. doi:10.1177/00110000231186824
- Good intentions don’t screen it out. Among about 25,000 healthcare providers, most did not report conscious bias, but around 83% showed negative implicit attitudes towards disabled people. VanPuymbrouck, L., Friedman, C., & Feldner, H. (2020). Explicit and implicit disability attitudes of healthcare providers. Rehabilitation Psychology, 65(2), 101–112. doi:10.1037/rep0000317