Ep 27: AuDHD Experience - Therapy Adaptations for Neurodivergent Folk (AuDHD, ADHD & Autism) — What's the Point?

🎙️ Ep 27: AuDHD Experience - Therapy Adaptations for Neurodivergent Folk (AuDHD, ADHD & Autism)  — What's the Point?

"Barriers aren't a 'you' problem — they're an 'us' problem to manage together."

Hi friends. If neurodivergent people are already showing up to therapy, why do affirming adaptations even matter? In this solo episode I work through that question from my own clinical experience and lived experience as an AuDHD psychologist. We map the barriers that keep neurodivergent people out of the therapy room — physical, psychological, emotional, sensory, and cognitive — and then walk back through the same five to look at small, practical, often low-cost changes that make care genuinely accessible. From externalising working memory and body doubling, to trauma-informed safety, non-fluorescent lighting, situational mutism, and a cushion instead of new chairs, this one is for neurodivergent listeners deciding what to ask for, and for clinicians wanting to do better.

A note on the evidence: I'm speaking mostly from clinical and lived experience here, not a deep RCT base. Where I mention that neurodivergent people "endorse" adapted approaches as helpful, that's about acceptability and client-rated helpfulness — how much people value these adaptations — not proven treatment efficacy or effect sizes. The main study behind that point is Paynter, Sommer & Cook (2025), who asked autistic adults to rate the helpfulness of specific therapy adaptations. The passage on perimenopause and sensory gating is an emerging, still-contested area, not settled science — hold it lightly.

Takeaways:
• There's no single "neurodivergent barrier" — physical, psychological, emotional, sensory, and cognitive access all matter, and they stack.
• Affirming therapy is trauma-informed by default; many of us carry complex stress and iatrogenic harm from past care.
• Speech is never a choice — situational mutism is overwhelm, not defiance.
• Meltdowns are overwhelm, and what looks like social anxiety or agoraphobia is often sensory-cognitive overload.
• Most adaptations are cheap: in-session alarms, chunking information, body doubling, dimmable lights, a cushion, starting on time.
• Clients: you're allowed to ask for a reasonable accommodation. Clinicians: mostly, just ask.

If this was useful, please share it with a clinician who needs to hear it — that's the single best way to get affirming care to more people.

📚 Reference: Paynter, J., Sommer, K., & Cook, A. (2025). How can we make therapy better for autistic adults? Autistic adults' ratings of helpfulness of adaptations to therapy. Autism. https://journals.sagepub.com/doi/10.1177/13623613251313569

Educational content only — this is not therapy or personalised clinical advice.

We are different, not defective.

Keywords: neurodivergent therapy, AuDHD, autism, ADHD, affirming practice, therapy adaptations, accessibility, situational mutism, sensory overwhelm, trauma-informed care, clinical psychology

Transcript

SPEAKER_00 0:00

Putty potty potty potty potty potty potty potty potty potty potty potty pot podcast, putty potty potty potty potty potty potty potty potty potty potty potty pot podcast. We love an audio stim and self-acceptance. It's the Audi HD Psych Podcast. Hello friends, welcome back to the Audi HD Psych Podcast. I'm Murren How with Clinical Psychologist, and we are different, not defective. If neurodivergent people are already engaging in therapy, then what's the point of affirming adaptations? And what can we do for them? Well, I'm so glad you asked, because that's what we're going to look at today: therapy adaptations for neurodivergent folk. Audi HDs, autistic people, ADHDs, those with learning differences. And we're going to do that by asking, what's the point? And then by looking into just a few ways we can address some of those things. So we'll start with that broad question: what's the point of adaptations in therapy for neurodivergent folk? And I guess we need to go back a little bit and ask, why do we become helpers and therapists? There are some who do that to earn the big dollars. And if that's you, this is probably not the podcast for you. But I think we have to earn a living, obviously. But also, most of us have had difficulties in the past, or certainly many of us have, and we want to use that experience to try and help other people have an improved experience of their life by not having to have difficulties themselves or reducing them. Then the counter question is why do we engage in therapy? And I guess for many people, it's to manage difficulties that we're having right now, to understand ourselves better, and to prevent difficulties in future. So to improve our experience of our lives. So therapists and clients very much aligned in that goal. What prevents neurodivergent people from getting the care that they need, particularly in therapeutic settings, but arguably in healthcare settings more broadly? And there's a lot that goes into that. There's the physical, the psychological, and the emotional. Now, I want to point out that today I'm speaking from my own experience and my own suggestions. There is a bit of literature out there, and I'll link to that in the show notes, that shows that adapted CBT and a couple of other things have been demonstrated to be endorsed by neurodivergent people as being helpful, but there's not a lot of the gold standard research out there on this one. So I'm going to share my point of view and my clinical experience. So there is the physical, there's the physical access that can be a barrier. There is the psychological, there's internal things that can be a bit of a barrier for me. There's the emotional. If I'm too scared to come to therapy, I won't. And then there are our sensory differences. Sensory impacts can overwhelm us and prevent us from engaging. And finally, and probably centrally, there are cognitive differences. And I'll go through each of those briefly. So, in terms of physical barriers to engagement for neurodivergent people in therapy, we have a lot of co-occurring health difficulties in many members of our communities, from chronic pain to gastrointestinal upsets to so many other difficulties, inflammatory and autoimmune difficulties that are seen at higher rates in our communities than they are in the broader community. And we need to account for those things. We need physically safe access. If I'm in a wheelchair and I don't have room to come through your waiting room into your therapy room, that's a problem. It needs to be a physically safe space. Obviously, we have compliance in most Western countries now that meet these, but it's something that we have to consider. But safety is not just physical, there's also psychological, emotional safety. I need to be able to trust you for me to be engaged in therapy with you, and that entails a lot. Many, many neurodivergent people have experienced iatrogenic harm. That is stress and sometimes trauma related to seeking help in the systems of care that we have, but actually having the difficulties made harder by that. But it's so much more than that. There are many autistic people have flat effect, so they don't we don't seem as distressed as a typical person may. And so we can be minimized and invalidated. This is the type of thing that comes into psychological and emotional safety. We have a lot of differences. We have a lot of complex stress and trauma in our community. So neurodivergent affirming therapy should be trauma-informed. I don't think it's unrealistic to expect that most of our community have experienced complex stress or trauma. The minority stress that we experience, all of those little things that the typical person doesn't have to deal with, they all add up and can increase our difficulties. And they need to be managed or at least considered. What else is there? There's our sensory experience. You know, so many of us have sensitivities to light or sound, busyness, textures, um, smells, and all of those can become a barrier to me engaging in any kind of healthcare or support. Then of course, there's busyness that I might have just touched on. That if I have my clinic in the middle of a shopping center at Christmas period, that's just not accessible to so many of us who the constant movement, lots of children, Christmas songs, it's Christmas, those sorts of things can be really overwhelming. We need to consider our emotional experience. If I've got complex stress and trauma and sensory differences, and I become overwhelmed by busyness, my anxiety and stress will be through the roof. And that in itself can create a barrier to some people getting out of the car and coming into a session. There are our cognitive differences. You know, neurodivergence is quite literally brains developing differently and functioning differently. And that's those cognitive and executive processes that we often talk about. What are they? In ADHD, we often talk about working memory differences. In autism, we talk about those rigid patterns that kind of need for expectations to be met. We can talk about processing. Sometimes we process things in a different way at a different speed, or we're processing a lot more things than the average person. So our processing of new information can be can cause difficulties and barriers to engagement. Our learning style, I'm somebody who I need to be playing with something when I'm thinking heavily. Ideally, if I can be standing up walking around while I'm learning, that's great. Some people need things in a visual form, some people need things in written form. Some people I also learn really well by engaging in dialogue. Probably that's the best way that I learn. That's a style of learning that if I don't take that into account as a therapist, then I'm making it harder for you to engage in the process. And then it's a thing, and this taps into our sensory experience. There's a cognitive function called sensory gating, and that's essentially the ability for me to pay attention to this pen and block out the sound of cars going past, because that's not important to me right now, writing with my pen is. Sensory gating is that element of my brain's functioning that blocks out the irrelevant stimuli, sounds, smells, sights. That's something that we notice is quite different in our community as well. And particularly midlife women in perimenopause with those changes of estrogen reduction, and then other neurochemicals, dopamine, serotonin, GABA, are impacted. And sensory gating is one of the things that we have increased difficulties with, or at least women in perimenopause have increased difficulty with. So knowing the stage of life that somebody's at and how that impacts on engagement and therapy is really important. I touched on emotional experience. If I have anxiety just in being out in public, because I've learned I get cognitively and sensorily overwhelmed, not sure if sensorily is a word, but let's pretend today, uh, overwhelmed, I might develop anxiety about being out and about in public, which may look like social anxiety or agrophobia, but is probably, or in many people's case it is, actually sensory and cognitive overwhelm. And that's often what's happening when we see, and I quote, meltdowns, it's really overwhelm because there's so much going on that I'm having to deal with. As a therapist, as a clinician, as a clinic owner, I need to consider these things. I need to work out how I can manage that for people so people can actually get here into the room with me and engage in improving their experience of their life because that's our shared goal. What else? I mentioned iatrogenic harm before, and so having had lots of experiences like that can be an inherent barrier to me being able to come into the room. Me not being able to communicate with you once you're here, me not being able to interact with you in a way that works. So, me expecting you to communicate in a typical way, to think in a typical way, to learn in a typical way. You know, one great example of this is I work with a lot of neurodivergent people. I work exclusively with neurodivergent and queer folk, um, one or the other, or often at the intersection. And some people really, really vibe with my particular conversational style of therapy. Um, other people don't. Other people don't enjoy the speed at which I speak and the number of ideas that I wind in because that's the way my Audi HD brain works. I need to accommodate that. That's my job as a therapist. I need to think to myself, what are the characteristics of the person in front of me? What's their history? What's their current stresses and sensory and cognitive experience? And I need to manage that. If you don't, if you don't read information and retain it, and I give you loads of stuff to read, I'm making therapy harder for you. If you learn by pictures and mind maps and things like that, and I do everything verbally, I'm making it harder for you. But by simply asking people, how do you learn? How does therapy work for you? we can manage some of that. So I touched on um overwhelm and what we can. I'm sorry, there's a plant falling down beside me. Um I touched on overwhelm before and sometimes social anxiety, and how that can be a barrier. So if I have had meltdowns as a child and I get overwhelmed and have panic attacks as an adult, and I have social anxiety, that can lead to a fear of judgment. That and a lot of other stresses where I've learned that I'm doing it wrong can lead to a fear of judgment. So if I send you home with some CBT homework, my favorite example, and you don't get it done, that might be a barrier to you coming back. And I need to be able to manage that also. Your trauma history plays a big role if I happen to use particular language, and that's a part of your trauma history, even if you have engaged, that can be a barrier to you returning and doing all of the background work at home, that really therapy is done. And communication and social differences. So the way I speak, the language that I use, if I speak, I heard a wonderful speaker talk about situational mutism. We call it if we diagnose selective mutism, but that implies that people are choosing this, and in my experience that's not the case. It's usually overwhelm and other barriers to speech, it's never a choice. Situational mutism, do I have a way for you to be able to communicate? Do I have an understanding of situational mutism to be able to let you downregulate, to let you calm down so that you can speak, or can I work around that? Can I just sit with you in whatever's going on for you without expecting you to engage? A lot of our community, we don't trust people easily. Can I allow you three or four sessions to get comfortable with me before we actually get into the therapy? Which that is in fact therapeutic. Uh, you know, typical person comes in, 10 CBT sessions is the you know the fantasy, uh, and off they go. Session one, background interview, session two, we crack on with the behavioral experiments or the behavioral activation. With most of the people I work with, that's not the case at all. We take time to get to know one another and to understand you as a person coming into chat with me. I need to understand all of those things. I need to know how you communicate. I need to know what your past is, and I need to know what your style is. Do you do I expect you to make eye contact and that's just not your thing? Partly because it's not your thing, partly because perhaps you've put so much energy into masking, it's become a social anxiety avoidance as well. I need to understand what my expectations of you are. So I guess to put a little summary of that, what are the barriers? What's the point? We want to improve experience. Uh, whether it's me helping you build skills to improve experience, or you as a therapist helping me as a neurodivergent person build skills to improve my experience, skills and understanding. The barriers are many. They are my cognitive differences that are the center of neurodivergence, which influence my emotional differences. ADHD is known for emotional impulsivity, as is autism to some degree, arguably, when we're overwhelmed. Do I have capacity to understand that and recognize that if you start to get frustrated, then that's not a you thing. That's uh characteristic, and if I don't take that to heart, obviously uh violence and abuse notwithstanding, if I don't take your frustration to heart, then I'm reducing a barrier to your engagement in therapy. So there are those cognitive differences, there's the emotional differences, stress and trauma history, physical differences, and physical access. And we're talking about accessibility here. The adaptations are accessibility adaptations. So, how can we manage those? And obviously, I can't go through everything that I've listed and the things that I haven't listed, but we could talk about a few. So, what can we do as therapists? Understand neurodivergence first and foremost. Do the training, do the reading, speak to neurodivergent people and understand neurodivergence. Understand the characteristics, understand that they come with both strengths and weaknesses. Don't pathologize just because of a label like autism spectrum disorder or ADHD or learning disorder. Ask the questions, ask about people's characteristics, ask what people need to feel safe and engaged in therapy. And if you feel that somebody has a motivation problem, that's a barrier for us to work together to manage. Because if there's no motivation to do the homework, then the homework has probably been set in a way that hasn't been motivational, and we should be able to work around that. Don't let a diagnosis overshadow somebody's entire experience. The diagnostic overshadowing is a problem we've talked about in previous episodes, but it works in so many ways. It can hide existing diagnoses and difficulties that we then attribute to the wrong thing. But we can also look at somebody through the lens of difficulties when actually that's not the whole experience. Understand neurodivergence. Understand the person in front of us. We can ask the questions, ask what's happening in the person's life, and ask what the person needs. Have processes that make it easier for neurodivergent people to engage. Have language that's accessible for people. Obviously, not everybody's going to need every accessibility measure, but if we put them in place, then we don't need to worry about them later. Make sure that things aren't overwhelming. Let us not be so rigid about our therapy process. We know that adapted CBT is something that's really helpful for a lot of neurodivergent people. So sticking to the same old structure is not neurodiversity-affirming practice, and it is creating a barrier to engagement for neurodivergent people. And adaptation is not setting as much homework, setting different types of homework that are much more easy to engage in. Use culturally appropriate tools, use things that are not normed on the general population, use tools and psychometric tools that are normed on neurodivergent populations so that we're actually getting real measurement of people's experience. In terms of interpersonal, understand that we are human as well, we are flawed as well, and we make mistakes. And that's okay. Being perfect is not a part of being human. Acknowledging the things that I can improve is the first step to rupture repair if we make a mistake and cause a rupture in our therapeutic relationship. And especially in the context of biatrogenic harm, if we cause a rupture, we need to work really, really hard to repair that. From a client perspective, also, we need to consider that there are resource limitations. If somebody doesn't have the money to change the thing, uh then hopefully they're doing the best that they can, as I touched on. But not all of our needs can be met by every single clinician. And that can be a dialogue about, you know, these are the five things that I really need to address. These ones are not great, but I can get by without them. Can we address these five things that are really making it difficult for me to get into the therapy room, to get the homework done, to achieve the therapeutic goals? So with those cognitive differences, I guess really simple things. If I have a working memory that's constantly tied up with all the details, or if it's it's somewhat less than my other cognitive abilities, then we can externalize. If I need you to do some homework, can we set alarms to do that homework in session so that we can't forget it when we walk out? Can we send an email reminder or a text message reminder, you know, halfway between now and our next session as a reminder for that task? Can we use a notepad, pen, diary, journal, whatever it is? Can we manage that working memory difference? Can we get some social accountability, some body doubling involved to do the thing, our partners, our friends, our parents? For processing speed and processing and learning more generally, ask the question and don't be afraid to tell your therapist what your characteristics are. Oh, you know what? I'm always thinking lots of things, so I need you to give the 50th thing a little bit slower for me. Or I'm always thinking 50 things, so I need you to give me the information in little chunks that I can hold there with the other 50. Or perhaps if you need structure and routine, as is really commonly seen in autism, then I can have that lovely agenda. I can have my structure, five, ten-minute check-in, check our homework, if we had some, then what are we working on today? Then a summary of what we've done, and then our planning for in-between sessions and next sessions. We can have that structure good to go for you every single time. If that structure doesn't work for you, can I adjust to that? If you're an Audi HD or an ADHD who bounces from one thing to another, can I work with that? And if not, is that a you problem? Or is that an us issue to manage? That's an us barrier to manage. Physical, I won't go too much into the physical access side of things because that's certainly here in Australia, that is a compliance-related thing for safety, pardon me, and just for physical access. For emotional barriers, we as therapists can be trauma-informed and we can again ask if you're comfortable sharing that trauma with us, then we can make sure that we don't inadvertently trigger it. Your sensory differences, simple things, our sensory differences, I don't want to talk at you. Um, our sensory differences, we can have non-fluorescent lights because we know that they can be problematic for a lot of neurodivergent people. We can have dimmable lights because we know that sometimes lights are too bright for lots of us. We can have quiet areas or the best that we can to have non-busy areas for people to go and desensitize and be away from all of the stimulus and busyness. What else can we do? Well, psychological safety. I can earn your trust. I can find out what difficulties you've had in the past, how they affected you, and we can work together to make sure that we don't trigger those again, that I don't inadvertently do that. This is actually something that happened to me once. It wasn't a neurodivergent person, but I used language that I used jokingly. And it was actually language that was a part of their trauma history, and there was a lot of repair that I needed to do to make them feel safe around me again, and that's such an important thing for us to consider. So there really are too many things for us to be able to cover in a single session, but I guess to the therapists, ask. All we can do is ask and work with the information that we're given. Ask about past stress and trauma, ask about cognitive characteristics, about sense of safety, emotional difficulties, ask about physical access needs. I recently had somebody uh mention to me that all of the chairs were not a good height for them to be able to sit in and leave easily. Now, as a practice owner, I can't afford to replace all my chairs. But what I can do is get maybe a cushion, which is in fact what I'm going to do, getting a cushion that that raises the chair up a little bit for that person so that they still are able to sit and wait comfortably in the waiting room. Often we don't have the resources to do everything we would like to, but we can usually find a workaround that manages a barrier or an access difficulty for people. And knowing ourselves, knowing what are my biases, what are my expectations. You know, I'm I'm an Audi HD, I'm a weirdo, and I still catch myself with this sort of internalized normal ideas for the broader community that just don't fit with our community. And I'm constantly reflecting on those and trying to challenge them. We need to understand our biases. Um, and as clients coming in to talk to us, don't be afraid to ask for a specific accommodation. If there's something that you notice in my practice, my clinic, your therapist's room, your GP's room, don't be afraid to ask for a reasonable accommodation. If there's all really hard seats and you have a condition that makes it really difficult to sit there, ask for a cushion or ask if there's a different seat that you can use. If your therapist's always late, don't be afraid to say, hey, can we start on time? Because that affects my expectations and that causes me a whole lot of stress. So I guess that's about where I'll leave it today. I wanted to talk about why adaptations are important. I wanted to talk a little bit about what we're here to do in therapy and healthcare more broadly, and a little bit about some of the small changes that we can make, small questions we can ask that make a big difference to neurodivergent access to therapy. Well, thank you very much, friends. It's been a pleasure to monologue at you one more time, and I shall chat to you next week. I will also say thank you for your patience as I went to the Neurodiversity Affirming Conference this week, which took up a fair bit of my time in pure pleasure. So I'm just getting this one a little bit later than I'd planned. But thank you again, and remember we are different, not defective. See ya.