Neurodivergence and therapy

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We've also got shorter takeaways from episodes over on the blog, plus a whole range of free downloadable resources on our website, including a guide for family and friends to understand neurodivergence and a content toolkit that helps you when going through all of our juicy content. So whether you're looking to go deeper or just want something practical, there's plenty to explore. You can find everything at ndwomenpod.com. Alrighty, let's get back to the episode. Hello, this is the neurodivergent woman podcast. I'm Monique Mitchellson and I'm a clinical psychologist. And I'm Michelle Levoch and I'm a clinical neuropsychologist. This is a podcast where we center and showcase neurodivergence women from all walks of life, covering autism to ADHD and everything in between. We aim to educate and inspire women who think differently. So today on the podcast, Michelle and I will be discussing how we adjust therapy to suit neurodivergence. And we'll also discuss common mental health issues that can overlap or come up in the therapy space when we're working with neurodivergent clients. So Monique, when you're working with a neurodivergent client, how do you usually adjust the therapy process or the therapy space? Well the number one thing is to actually be aware that your client is neurodivergent because so many people are under diagnosed, particularly women and people of older generations. It's our responsibility as clinicians whether we're working in mental health or physical health to educate ourselves on neurodivergence so that we can adjust therapy appropriately. So once you've realized that your client is neurodivergent, what types of things or is there anything that you would do differently in that space? Well first I would really get to know my client because everyone that presents with neurodivergence, whether it's ADHD, autism or anything in between, every person is different and there is a saying that if you've met one person with autism, you've met one person with autism and I think that extends to other things as well. So based on really getting to know the client, getting to know their history, what I study is their nervous system because how regulated or dysregulated their nervous system is is going to tell me what we need to focus on in therapy and also how do they respond to the stresses in their lives, what trauma load are they carrying and based on what resources a person has, so what support system, what are their own coping strategies, then I'll select different types of therapies. In my brain in therapy, everything is very systematized. So when I learn information about someone that I'm working with, it kind of gets plugged into this analytic data system in my brain that has only subgroups and like pathways and it just tells me okay this strategy is going to fit this particular need, this other strategy is going to fit this other need and I kind of look at it as building up the person and showing them how to build themselves up from the ground level up in their nervous system and their regulation skills because what I've tended to find and this is just my personal experience is that people who are neurodivergent normally are quite sensitive and then nervous systems are normally quite sensitive, so I might bring up a particular topic in therapy and you know such as like okay let's let's talk about mindfulness or practice some mindfulness technique for some people going in and paying attention to their thoughts and feelings that might be too overwhelming or even not a skill that they have in their will halves yeah because I find that often you know as a coping mechanism sometimes people who are neurodivergent as we chatted about in our last episode can tend to lean towards that sort of disassociation side where a way of managing feeling overloaded constantly or overwhelmed constantly is just to completely shut down and so then when we come into the therapy space and the therapist is saying okay so tell me like how do you feel about this what are you thinking it's sort of like well I have no idea I'm here I'm in the room yeah and I think the biggest thing is to not make assumptions as a clinician about watch skills the person has or what do they know because often people don't know what they don't know and so I might you know start to work on you know building a mindfulness skill but we need to really dial it back and start with something maybe more simpler such as some psycho education on what are emotions or what are body sensations because a person might not be able to pick up on those or they don't know how or never thought about it in that way so I normally start off with a lot of psycho education about emotions different thinking patterns body sensations and then go to strategies but before getting into the strategies in particular it might aim the whole time in a therapy session is to try and ensure that the client is kept within their window of tolerance because yeah sometimes if I'm introducing too much information too quickly it might be too much for the person to process or tapping into a big emotion again if they haven't built those emotional regulation skills it might be too much for them to process in the session and then they might go into potentially a meltdown or a shutdown so they might go up into fight or flight or down into freeze and not be within that window of tolerance where they can be present in the room and sit with an emotion without it overwhelming them so it sounds like the goal in that kind of early therapeutic process is really to arm the client with like a toolbox of skills and strategies to sort of manage uncomfortable feelings be able as you were saying in our last episode of Minig to sort of sit with an uncomfortable feeling but not so much so that it's going to completely overwhelm the person so what types of things would you use to upskill a client within that space what types of things would you suggest or support them in developing yeah so I talked to them about mainly psycho-education about anxieties we talk about what are the symptoms of anxiety in their body and of the fight or flight response so really kind of increasing their knowledge of their own bodily response yeah I teach them diaphragm breathing which works really well to help with panic attacks and to just try and keep the body in that window of tolerance I teach them grounding techniques so looking at mindfulness like with your five senses what can you see what can you hear for people with ADHD it can be difficult to focus on doing like a meditation when you're just sitting still so sometimes actually get up with the client in the room and we'll do a walking meditation and we walk around but very slowly and so by really slowing down each movement it's being aware of each part of your foot that is touching the floor and labeling in your mind you know heel middle toe remember might do that for a couple of minutes you know at the start of a session to get the person into their window of tolerance so it's interesting because I know you know for a lot of people hearing things like that like oh you know we do breathing and we think about our feet it can sound a bit like oh that I don't understand how that would help or I don't get like how that would actually support regulation and I definitely remember you know for me before I knew the why of why is diaphragm breathing actually helpful I had the same thoughts and be like oh my god do not tell me to breathe this is infuriating but I think the really important thing to mention there is that not all breathing is created equal so when we talk about and when psychologists talk about breathing or diaphragm breathing in particular the reason that it's actually so helpful is it actually stimulates different neurotransmitters in your brain and supports the release of regulation at a and neurochemical level. So sometimes when we think we're deep, breathing, really what we're doing is hyperventilating, a form of hyperventilating. Right, so breathing quite quickly into the top part of our stomach. That actually triggers our brain to think that we're still in stress and it releases more stress chemicals like cortisol and adrenaline, which actually perpetuates the stress cycle. When we breathe really deeply into the bottom part of our lungs and crucially when we focus on our lungs expanding outwards laterally rather than forwards, that has the opposite effect. That signal to our brain that the threat is over and reduces the amount of cortisol and adrenaline that's pumping through our body. So really slowing your breathing down and breathing in through your nose, out through your mouth and sometimes when you're first starting this practice, actually having your hands, placing your hands on the sides of your ribs and really focusing on breathing into your hands so you can literally feel your hands expanding out. Breathing in for account of four through your nose and out through account of five through your mouth and following that process maybe three or four times, no it's not going to make the problem go away. It's not going to magically fix everything that's going on but what it will do is actually lower your level at a biological level of stress and help calm your nervous system down so that you're in a space where you can think more clearly. Yeah exactly and I find that a lot of people when they come will be like oh yeah I've heard of breathing. I do it every day. Yeah you know and breathing techniques blah blah blah but like no one's really gone through and actually done the proper psycho education and really explain why you know or they may not have taken the time to actually practice the exercise and have that experience so often I'll get people to rate their level of stress on a scale of zero to ten and then in the session we'll do at least two to three minutes of the diaphragm breathing and then I'll get them to rate their level of stress they feel in their body after doing that and often it will be a lot lower and so they've actually had that felt experience of wow this works. That's a really key point there I think about the felt experience and often people who are just used to operating an extremely high level of stress in terms of you know how stressed your nervous system is don't actually have a comparison point for what it feels like to feel calm in your body so having those experiences and I think the therapy room is a really good place to practice doing that where you can actually yeah exactly as you said Manique have that felt experience of what does it feel like when I'm not at this level of stress. Yeah that's a good point because when we're going through the education about anxiety again I explain I guess like having an anxiety thermometer and again on that scale of zero to ten I ask people where would you at every day level of stress or anxiety be even if there's nothing like major major going on and most of my clients will say oh five or a six and then we talk about how well if you're creeping up close to an eight nine or ten that's sort of a point at which it's going to be really hard to bring yourself back down and that's the point at which a lot of your strategies are going to be difficult to use or they'll take a lot longer to have an effect so it's about monitoring where you are on that stress scale and noticing if you're starting to creep up and then actually using your techniques like the diaphragm breathing and continually bringing your score down with the diaphragm breathing so that you're never hitting that eight nine ten point and that's where you can start to you know try to work with your nervous system and do a little bit of retraining and I think the point is that some of these strategies in your toolkit they're not going to change your neurodivergence you know they're not there to make you a different person or change your genetics some people are born with a higher sense of anxiety in their body and they are more sensitive to their nervous system and that's why they need the extra supports and strategies to kind of regulate their nervous system more than maybe somebody else needs to yeah and I think something that I find really important that is really important in my practice for everyone but again particularly for people who are neurodivergent is really explaining the why of certain strategies because you know you can tell someone to do something and say oh this will help but often if the person doesn't know why it's helping or why you're suggesting this thing it's really difficult for them to implement that into their lives I think you know with the mindfulness stuff and the connection to body and really thinking about you know how your body feels in certain situations or you know tuning in and then labeling things like you were saying before you know heal soul toes whatever the reason that that's a strategy is because that actually strengthens and this is a biological level strengthens the connections in your nervous system between different parts of your body and your conscious awareness sometimes the reason that we might not know what we're feeling is because the pathways between that particular or those particular parts of our body and then our language center which enables us to kind of label those sensations or feelings isn't super strong because it hasn't been well-trodden so the more we tread those pathways and the more we engage in those activities that really kind of consciously involve focusing on these different sensations what we would call those things and being aware of that all of those links become stronger so that can really help with what you were talking about before many which is your anxiety thermometer right because it's really tricky to know where you're sitting on that if you're not actually aware of what's going on in your body and the more you're aware of how you're feeling and what your body's telling you the more insight you have into where you are on the say anxiety thermometer and then the more you can do about it because often with clients who are neurodiverse or clients who have a really hard time connecting to those felt sensations it's not actually until we are at an eight that they're like okay I'm feeling upset or overwhelmed and then as you were saying it's so hard to put things in place to bring yourself back down when you're at that level and then it's a meltdown or a shot down panagotac or dissociating but yeah I really like what you said about the pathways in the brain and it's like starting off with piddly little you know side roads and then practicing so that you get you know super highways in the brain yeah love that and I think the other thing to say there too is that we often think about brain as just the mushy stuff that's in our skull but our brain is our entire nervous system our brain extends all the way down to our visceral organs it's our whole nervous system structure so literally go onto google and google image search human nervous system and you'll see how far our brain actually extends into our body so when we talk about pathways in the brain it's not just in the mushy thing in our skulls it's actually our entire connection to different areas of our body yeah hearts are lungs digestive system our bals cervix for women yeah so like a lot of people who in your divergent will have digestive issues so if you make that link with people and go hey actually practicing diaphragm breathing that could potentially help settle your gut down you know and help you not to have diarrhea you know or it could actually you know there is studies out there linking CBT and stuff like that with treating IBS people can see the benefits so in terms of how your room is set up mannequin and things you kind of allow in the therapy space or tools you might utilize in the therapy space can you talk to us a little bit about that yeah so my room is set up for neurodivergence um the lighting is dim there's not the overhead fluorescent lights there's warm lamps have a lava lamp in my room all the colors are soothing um depending on the person I might have essential oils going there's natural light and I have I guess a toolkit full of different sensory tools that people can use in session especially while they might be talking or doing some talk therapy to fidget with some got like a fidget popper I've got a cool sort of like light up lamp that has glitter in it um I've got like a puzzle ball um different sort of sensory objects and what I'm working with people that have ADHD and they might be a bit hyperactive we don't have to sit down hmm the whole time sometimes we'll be playing a game like I've got a basketball hoop on one of my walls and we'll be like shooting hoops and trying to see you know who can score um the basketball hoop sometimes if a client doesn't want to sit I guess um face on to me or have to look me in the eyes like that's completely fine we sit sort of angled sideways or like away from each other um yeah Yeah, we don't have to have unnecessary talking if the client doesn't want there to be unnecessary talking. There might be periods of silence where the client's regulating themselves. So yeah, it's about just using sensory toys and fidgets and being aware of the sensory environment in the room. And I encourage my clients to bring in their own sensory soothing devices. So I've had people come out in with like fidget poppers or their favorite blanket or like a stuffed toy. It's about allowing the client to unmask in the therapy room as well. So going, you know, if you're masking, you don't have to do that here. You can stim in front of me. We don't have to have eye contact. You can get up and move around. You can sit on the floor. You can take your shoes off if you want to. (laughing) So it's really just being attuned to the client and what their needs are. What does their nervous system and sensory system need to feel safe and to feel attuned? And that might be the first time that they've been able to unmask as an adult in the room with somebody else, you know? So that can be a very powerful experience in itself of safety. - Yeah. - I think that's really relevant as well for the idea of a window of tolerance because if someone is expending a bunch of energy, you know, trying to sit with sensory discomfort or stop themselves from stimming in a way that they want to or feeling restless internally, feeling that kind of cabin fever sensation of sitting for too long, something that is just uncomfortable for them in the space. Then that's actually taking up space on that anxiety thermometer. And we might not think of that as anxiety. We probably wouldn't label it as such, but you know, another word I guess for an anxiety thermometer is just our nervous systems stress the moment up. You know, stress essentially in its core meaning is pressure on our nervous system. How much pressure is our nervous system dealing with it at that point in time? And you know, there's so many things that can put pressure on our nervous system, sensory stuff being one of them. So, you know, in a therapy space when we're really actually trying to deal with some difficult stuff or introduce concepts or ideas or tap into feelings or past traumas or whatever's going on, that's really difficult to deal with. What we want to try and do is empty as many stress points as we can, like unnecessary stress points. There's no need to feel sensory discomfort. So if you feel like that's something that you're having to manage in your therapy space and there's aspects of that space that, you know, making you feel uncomfortable, I would really recommend just bringing that up with your therapist because they likely have no idea because it's likely not stressing their nervous system. And sometimes if you just say, hey, actually the lights are kind of making me feel nauseous, would it be okay if we turn them down? Or, you know, I really actually prefer sitting on the floor, this couch is kind of making me feel a bit yark. Can I just sit on the floor? Nine times out of 10, your therapist is going to say no problem. And if they do have a problem with that, they're probably not the right therapist for you. - Yeah, absolutely. You know, I think it's really about the client. You know, I've had people ask me if they can wear sunglasses during the session. - Sure. - And I've said, yeah, sure, or can we lower the blind? Or I've had people tell me, look, the waiting room is too much for me, it's too loud and noisy, it's very crowded. So we've had an agreement what they might wear outside the clinic, you know, in the garden or sitting the quiet space just outside my room. So again, it's just about being flexible. Some other things that are worth noting is that say if a client is mute, so they're overwhelmed or they don't want to talk in a session, part of being flexible might be coming to an agreement that, okay, you can just write down on a computer or a letter pad, what you want to talk to me about, and then I'll talk back. Sometimes as well, because a lot of neurodivergent people have auditory processing issues or short-term memory issues, I make sure I write things down on the whiteboard and I let people take pictures of it or I give them handouts and I make sure I provide a lot of visuals. If it's just talk, talk, talk, they might not retain it. Yeah, that's a really good point about the visuals and having that as sort of a take home aid for people. And if you feel like in your therapy space, that's something that you would really benefit from or you kind of would prefer things were written down so that you could see them better and retain them better, I definitely would suggest just advocating for that with your therapist and saying, hey, a couple of times, you know, I've left this space and I've had a really hard time remembering what we've talked about or the kind of points that we agreed on or strategies that we went over, would we be able to kind of write them on the whiteboard or could you give me a handout to leave with? Yeah, and one point I think as well with regards to therapy is sometimes because of having a smaller window of tolerance or just having, I guess, everyday stresses and then probably a trauma load. And then whatever issues, you know, a person's neurodivergence brings up for them. Sometimes therapy can take longer with people with neurodivergence and sometimes there'll be successes and sometimes, you know, things will go back a little bit and I think it's really important for both the client and the clinician to have patients. And to, you know, know that, yeah, sometimes it does take a bit longer. And yeah, some people just might need like that ongoing therapy or that support because maybe that's the only area in their life they're getting some support for around the neurodivergence or around managing stress. And yeah, for some people might be ongoing therapy over a long period of time to help them manage things. Yeah, absolutely. And I think, you know, for some clinicians, there's this sort of prevailing idea that therapy should have a goal and we should be working towards a goal and there should be a set number of sessions that are involved in achieving that goal. And if the goal isn't achieved in those sessions, then you should terminate therapy because the client isn't motivated or it's not the right time for them or for whatever reason. And that whole kind of notion is really, I guess, based on the CBT model. So the cognitive behavior therapy model, which definitely has its positives. I think, you know, there is utility in understanding how our thoughts impact our emotions and behavior. But it's really a model that, you know, kind of focuses on, well, if you don't want to feel this way, you just need to change anything about it and stop doing the behaviors that are making you feel that way and then you'll be fine. (laughs) Yeah, and that works for a certain percentage of people, but definitely not for everyone. Yeah, absolutely. And, you know, the idea of terminating therapy if something isn't, quote unquote, achieved within a certain number of sessions, I personally find quite discordant with my own values because exactly as you say, Manique, you know, particularly when working with a neurodave agent clientele, often there's so many complex issues that come up, it's often the first time that they've been able to have a space where they feel validated or feel like they're need our valid and they feel connected in a way. Personally, I really prefer a compassion-focused therapy model. So if you're wanting to learn more about CFT, Paul Gilbert has a lot of really great articles about what that process is. Yeah, and there's a lady called Kristen Neff, so Kristen with a K-NE-F-F, and she has a really good website that has a lot of free resources on it, including recorded exercises. She has a TED talk on self-compassion therapy and a really good book where she talks about her own personal journey with self-compassion. Yeah, great. So, you know, I think the primary focus of compassion-focused therapy is really that idea that when we don't have compassion for ourselves, it's really difficult to have compassion for anyone else. And one of our psychologists here actually, Amanda Donnet, has a great definition for compassion, and she talks about how compassion is empathy in action. So empathy being the ability to connect with and relate to an understand suffering, whether it's your own distress and suffering or someone else's distress and suffering, and then the action part of it is doing something about it. And, you know, in practice, that might look like, okay, I am really struggling to get out of bed right now because I'm so overwhelmed by everything going on and having a really hard time at the moment. The empathy component of that is, yeah, wow, that makes so much sense. Why I'm feeling so overwhelmed right now, I can really understand why my body is reacting in this way, why I'm feeling this way. And I'm not mad at myself for that. I'm not judging myself for that. Yeah, this is a completely understandable reaction. And I'm in a lot of pain right now, and I'm really suffering. The action part of it, so the other side of compassion, is I'm gonna do something for myself that's going to help me feel better. I'm gonna go on a walk today, and that's the only goal I'm gonna set myself. I don't particularly want to do that, but I know that's gonna make me feel better. It's like, you know, as a parent with a. a kid who is really sick, right? They might say, "Uh, I don't want to have that medicine that's disgusting." Actually, being compassionate to them is saying, "Oh babe, I know that this tastes so gross and you really don't want to have it, but you actually just have to have it because it is actually going to help." It's not compassionate to your child to say, "Oh, you're right, it does taste gross. Don't have it then." And then they just stay sick. It's not compassionate to yourself as an adult to say, "Okay, so I'm not going to do the things that I know are going to make me feel better." So, compassion-focused therapy is really about identifying the source of your distress, letting go of judgment of your responses around how you respond to stress, manage stress, and then putting in action things that you know are going to improve your mental health, improve your coping, improve your functioning in life. So, for me, CFT seems to gel more with my kind of preferred approach therapeutically and my sort of values. And I find it can be a really good place to start, particularly when someone has trauma work to do, because it's a nice place to sort of upskill in some of those regulation skills and increase that sense of self-compassion, self-awareness. Yeah, I see it as a really good way of building that inner relationship with yourself. And, you know, we all have an inner critic. Yeah, you know, that's just a fact, but it's building up that inner advocate, that inner friend, that supporting you, and yeah, just developing that ability to be kind to yourself. And I think, you know, for a lot of neurodivergent women as well, to like yourself, to actually be like, "No, I'm a likable person." And I like who I am, because sometimes a lot of that inner critic stuff comes from a core feeling that, you know, I'm not likable. And I need to change to be likable, to be someone that I, you know, this idealized version of who I would be if my life was perfect. Yeah, and I think self-compassion therapy is a really good way to help undo any guilt or shame that you might have around yourself for being neurodivergent or, you know, being in a world that doesn't fit you, and maybe you didn't know why. And I think it really helped with that process of unmasking. Yeah, that's a really good point, because I think, you know, the why of our behavior really matters. And sometimes when we're still trapped in that kind of framework of, well, there's something wrong with me, we might mask because we think, well, I have to, because I can't show people what's wrong with me. So that masking is coming from a place of shame. But when we've built that inner relationship with ourselves, as you've said, we need, we might, in some situation, still decide to mask, because we might think, okay, this isn't really a safe situation to kind of be my true self or, you know, I don't feel comfortable, but it's not coming from a place of shame anymore. It's coming from a place of intention and choice. We're not doing it because we feel like I have to, because I don't know, you know, my inner self will just terrify people. We're doing it because it's an active choice. And that makes all the difference. And it's not only masking that that's relevant for us well, you know, so often a coping strategy that is positive and helpful and compassionate can look the same on the surface as a coping strategy that's actually not helping us. So for instance, you know, isolating. Sometimes we might be doing that almost as a punishment towards ourselves. Like, oh my god, you're an idiot. Just never talk to anyone ever again. I'm just not going to call this person because it's going to burden them and I need to remove myself from society. You're isolating, but it's almost a punishment towards yourself. On the other hand, we could use isolation or time to ourselves as a really compassionate, useful tool. So we could be thinking, okay, I'm actually really overwhelmed by a bunch of really tricky social interactions I've had recently. And to re-regulate my nervous system, I just need some time on my own. And I'm going to just like create air, but I'm just going to go to bed earlier tonight or I'm going to watch my show in my room with the door shot, right? If we're doing that with the intention of supporting ourselves and we're thinking, this is something I really need to feel okay. And I'm allowed to do this thing because it's good for me versus using it as a punishment. Very different outcomes. So I think that it's really important to kind of reflect on why you're doing the things that you're doing to cope. And what purpose those tools are serving you. I guess one thing to mention about self-compassion therapy is, you know, it can be hard because a lot of people find it easy to feel compassion for others, but really difficult to turn it back and feel that compassion towards themselves. And it's just like what Michelle mentioned earlier about taking those small little country roads and through practice, turning them into highways. And it does get easier with practice. And yeah, just a couple of things I'd like to mention about therapy is that different things work for different people. So really keep that in mind and just keep trying things because sooner or later you'll find something that does work for you. And it's important not to sort of give up. And the last thing is, you know, if you're a clinician, listen to your client, don't make assumptions, listen to them, ask what do they want, how do they want therapy to go and run with that. So thanks for tuning in today guys. I hope going through the therapeutic process and talking about some tools that we use as therapists has been helpful. And don't forget to check out our Facebook and Instagram pages like and share them and our petition for adults with the diagnosis of ADHD and adulthood to access equal medication rights is still going so please check that out. Thanks for listening. Bye!