Many of y’all know that I have been using TherapyNotes as our practice EHR for over 10 years now. I’ve looked at others and I keep coming back to TherapyNotes because they do it all. If you’re interested in an EHR for your practice, you can get two free months of TherapyNotes by going to thetestingpsychologist.com/therapynotes and enter the code “testing”.
This podcast is brought to you in part by PAR.
Hey, guess what y’all, the BRIEF-A has been updated. The BRIEF2A is the latest update to the BRIEF2 family. Use the gold standard in executive functioning assessment to assess adult clients. You can preorder it now, visit parinc.com/products/brief2a.
Hello everyone and welcome back to The Testing [00:01:00] Psychologist. I am excited to be here with you to be talking about a topic that feels like we have needed to cover for a long time. Today, we’re talking about neurodivergent-affirming assessment with Dr. Matt Zakreski.
Matt has a high-energy, creative clinical psychologist and professional speaker who utilizes an eclectic approach to meet the specific needs of the neurodivergent community. He is proud to serve the Gifted community as a consultant, a professor, an author, and a researcher. He has spoken hundreds of times all over the world about supporting neurodivergent kids.
Dr. Zakreski is a member of Supporting the Emotional Needs of the Gifted, the National Association for Gifted Children, the New Jersey Association for Gifted Children, and Pennsylvania Association for Gifted Education. Matt graduated from Widener University’s Institute for Graduate Clinical Psychology in 2016. He is the co-founder of The Neurodiversity Collective.
This is [00:02:00] a really cool interview. Matt, I think you will see pretty quickly, is a very humble, very kind individual, easy to chat with, and we get into a number of areas related to neurodiversity-affirming assessment.
We start with some definitions around what is neurodivergent and what does it mean to be neurodivergent-affirming, we talk some statistics about neurodivergence in our country, and then we get into some specific tips around neurodivergent-affirming assessment practices. We talk about strategies for your website, for the scheduling process and paperwork, for financial communication, interviewing questions, the testing process and the report-writing process. So we cover a lot of bases here and I think there’s a lot to take away from this podcast.
If you are a practice owner and you would like some support in running your practice, my mastermind groups are [00:03:00] full until January of 2025, but I have two spots open for individual consulting, either via strategy session, which is a one off hour or more ongoing one on one relationship. You can get more information and schedule a call to chat about it at thetestingpsychologist.com/consulting.
Let’s get to my conversation with Dr. Matt Zakreski.
Matt, hey, welcome to the podcast.
Dr. Matt: Thanks so much for having me.
Dr. Sharp: I am very glad to have you. I feel like I say this more and more often, which is an indicator of something. I don’t know what, but I can’t believe that we have gone this many episodes without talking explicitly about neurodiversity-affirming [00:04:00] assessment.
It is such a hot topic that maybe will stay hot, maybe should not even be called hot because it’s part of the deal, we should be talking about it all the time, but it’s super important over the last few years and there’s a lot of energy behind this particular topic. So all that to say, thank you for being here. I’m really excited for our conversation.
Dr. Matt: That makes two of us. It really is a fascinating thing for me because people are like, are you just jumping on the hot new trend? I sit there, I’m like, I don’t know, am I? To me, this is what I live, this is the way I see the world.
To me, it’s like a restaurant, you want to be the hot new restaurant for a while but then you want to [00:05:00] be the restaurant people go to. You move to that, like it’s part of the fabric of the community. I want in a few years, 5 years, 10 years, that we consider the needs of neurodivergent kids like we would consider the needs of handicapped kids or kids with food allergies.
We’re more or less the same age; do you remember growing up, the kids with the nut allergies were, you wrapped them in a bubble. They were like, from the bubble feeling, what if the kid’s going to die? Now there’s the gluten-free table, the veggie table, the nut-free table. It’s part of the zeitgeist now. Knock wood, that’s what I would love to see my kids be in a few years.
Dr. Sharp: That’s fair. I think it’s getting more and more integrated into the fabric of school, work and media and so forth. I’m looking forward to diving into each of those areas and figuring out how we can do the best job as psychologists and [00:06:00] neuropsychologists as we can.
I’ll start with the question that’s always the top of the podcast, which is, why is this important? Of all the things that you could spend your life, energy, emotions on, why this?
Dr. Matt: The biggest thing for me is that I grew up as a gifted kid in New Jersey in the 90s. I’m from a small town with really good public schools. They had no idea what to do with me. I find it funny to no end that you get this thing where that’s why you moved to the town with a good public schools and I didn’t get a lot of those services.
They cobbled something together and then fast forward a few years, it’s high school. I’m getting [00:07:00] up to my eyeballs in high school work. At that point, they’re like, you’re really struggling more than we thought. Let’s make sure we’re not missing anything. Let’s assess you for ADHD. I basically broke the scale. I was a twice-exceptional kid all along, but I was so smart and capable that no one ever looked for those things.
Here I am now as an adult who specialize in working with kids like this, trying to make sure that I’m the adult for those kids that I needed growing up. I think like a lot of people in this field, this work is personal and professional.
The more I get at playing these spaces, the more I get to remind myself, it’s like right, that there are really good reasons to do this. There are kids who really need me out there. It’s an honor to get to work with kids like that.
Dr. Sharp: For sure. That’s [00:08:00] such a cool way to think of it. It’s funny, it sounds like we had somewhat parallel lives, different situate. I grew up as a gifted kid in a very small town in West Virginia. We did not have good public schools.
What that meant back then, if you were gifted, is that you got bust to some other not-so-great school and you got to play Oregon Trail all day on the computer because there was only one computer in the district, and so of course, I loved it. But looking back, I’m thinking, maybe that was not the most enriching environment.
Dr. Matt: How much did that actually help me?
Dr. Sharp: Sure. We played Oregon Trail and did a bunch of those little logic puzzles with the matrix; if so and so has to get across the river in two step, that kind of thing, but their hat is yellow and they can’t be with somebody else with a red hat, anyway, that kind of thing. Lots of those games. Like many people, the personal motivates our work. It sounds like [00:09:00] you’re in that camp as well.
Let’s jump into it. There’s a lot to talk about here. I’ll start with some background maybe just to set the stage. I know there’s a lot of varying definitions and operationalization of neurodivergent out there, but I’d love to start with your definition of neurodivergent. What is that? And then we can move to more of a definition of neurodivergent-affirming. How about that?
Dr. Matt: Neurodivergent is a person who has a quantifiably different brain. So a person with a quantifiably different brain, as we can look at brain scans and we see that brain has functional and structural differences that make it different than a neurotypical brain; a brain that largely functions as we would expect a brain to function.
Around 80% of people are neurotypical. That number is both lower and higher than you’d [00:10:00] expect, because it feels like everybody we see is somehow neurodivergent. They have a different brain because that’s why they’re ending up in our spaces, because we’re the translators. We get them from the neurodivergent world to how do you use that stuff to navigate the neurotypical world?
When I say there’s not many people, it’s like, wait, so like one out of five kids is neurodivergent? I’m like, right. So in your classroom of 25 3rd graders, you’ve got probably four to six kids who are neurodivergent in some way. That’s not all gifted, which is certainly my subspecialty, but it is the idea of ADHD, dyslexia, autism, OCD when we combine those things, we’re looking at about 1:5 kids.
I always start my definitions with the neuroscience because you still see people out there who are like ADHD, [00:11:00] isn’t that too much sugar? I hear autism and that’s just bad parenting. Dyslexia, those kids just aren’t trying hard enough, you hear those well-worn chestnuts.
So I’m like, these are brain things. I could point to a brain scan and say, this is a dyslexia brain, this is a gifted brain because it gives us that counter narrative to the idea that this is the kid’s fault somehow, rather than this flows from a literal brain difference.
Dr. Sharp: Yeah, that’s fair. I want to dig into that just a little bit because you mentioned OCD. That was interesting. That grabbed my attention. I feel like there’s some discussion around whether or not emotional concerns, we’ll just say emotional concerns, get lumped into neurodivergence.
I’m not sure if you split OCD [00:12:00] off from anxiety and depression or even PTSD. I’ve seen that lumped in. How broad does the umbrella get as far as your concern and in terms of a quantifiably different brain?
Dr. Matt: I put OCD in there because the recent studies out of, Penn State did a study on this, I believe it was Vanderbilt. They found the basal ganglia, which is a reward circuit in the middle of our brain is quantifiably different in OCD kids, so it really is a brain difference.
Obviously, OCD shows up in all sorts of different ways. I think OCD has not been as readily looped into the neurodivergent spaces, especially with kids in school, because OCD doesn’t necessarily impact learning in the same way that ADHD, autism, dyslexia, giftedness [00:13:00] do.
I see that kids who have that perfectionistic morality driven, you see a lot of that co-occurring with autism and giftedness. I list it because it becomes to me more of a social emotional neurodivergence in addition to its impacts on how we navigate the world.
When I would say depression, anxiety disorders, panic attacks, to me, that’s mental illness. It’s a different category and those things can be related to neurodivergences. In fact, they usually flow from that neurodivergence. I’m depressed because I have ADHD and I can’t figure out how to survive in this world.
What we’re really looking at here is functional brain differences that flow [00:14:00] downhill into behavioral and emotional changes, something like PTSD to your point. That’s what we would call an acquired neurodivergence. So a lot of this stuff is neurodevelopmental; the brain changes based on its developmental trajectories, but concussions, TBI, long COVID, these things are all acquired neurodivergences.
I’ve had four concussions, and neurologist who yells at me all the time for stuff like that. She’s like yo, you specialize with people with different brains. She’s like, your brain’s been different quite a bit. I’m like, yes, it has but thankfully all of those concussions have healed and my brain has returned to its typical neurodivergence.
Dr. Sharp: Sure. Baseline neurodivergence.
Dr. Matt: Just the normal ways that I’m weird, right?
Dr. Sharp: Fair enough. Let me throw one more thing in there just to get your thoughts at [00:15:00] the risk of stirring up a whole bunch of trouble, but asking these questions is important. I’ve also seen gender identity, gender diversity, that kind of thing lumped in with neurodivergence. I’m curious how you approach that as well.
Dr. Matt: I love that you asked that question because we have to be willing and able to have these conversations. What we know is that there is a significant overlap within the LGBTQ community and the neurodivergent community. The number that gets cited all the time is somewhere between 38 and 70%. That’s a lot of people. That is somewhere around, if we split the difference, we call it half.
When I think about my clients, I see primarily neurodivergent people, I have a highly LGBTQ group that I see. It’s not always the [00:16:00] presenting concern. It’s not always the thing, but it’s part of that conceptualization. What does that mean? Gosh, I wish I could tell you.
Our awareness of these brain differences is in many ways in its infancy, we are just learning how to do this stuff. I’ve heard a lot of different theories thrown around the campfire, I think they’re interesting. They’re worth further study. I don’t have access to a research lab, so I can’t do that work anymore.
What I would say is, it definitely has something to do with neurodivergence, but we don’t have enough information to draw any meaningful conclusions on it yet. I would say that it’s a correlation, not a causation at this point.
Dr. Sharp: Yeah, that’s reasonable. I look forward to digging in [00:17:00] and getting some of the research. I know it’s out there. I know people are doing it. I just want to see more of it. Let’s talk about neurodivergent-affirming, how would you define that?
Dr. Matt: Let’s use a metaphor here. Let’s say that everybody in your life is about 6 feet tall. They’re about average height for an American male. Jeremy, how tall are you?
Dr. Sharp: I’m 6 feet tall.
Dr. Matt: I am also 6 feet tall, so we are typical in this particular iteration of things. If you’ve got a person in your life who’s 6 foot 10, that is a person who is quantifiably different. They are in some sort of higher percentile of human height.
That height isn’t better or worse [00:18:00] than anything else, they’re just taller. They might be better at basketball, they might be able to get that thing off the top shelf in the garage and we’re very excited about that, but it’s not meaningfully superior. I think it’s important to push back against that narrative.
So if I was going to build a home for that person, I wouldn’t assume that the person I’m building this home for is about six-foot-tall, so I’d make my door frames about 7 feet tall; because that’s your standard American doorframe height.
If I ask the question of my client, hey, how tall are you as I build your house? And they say I’m 6 feet 10 inches, I’m going to build those doors bigger because I want to affirm that person’s way of seeing the world, and that’s really challenging to do because you have to do a lot of things differently than how the world is set up.
The world is set [00:19:00] up to teach and serve the middle of people where most people are. My favorite exercise to do on this is, if you’re having a dinner party, Jeremy, what would you cook for your dinner party?
Dr. Sharp: Ooh, I personally, I don’t eat a lot of meat, if any. I am always saying 90% vegan and so I’d lean in that direction and probably do more of a plant-based meal.
Dr. Matt: Love it. We’re going to invert this because I usually do it the other way, but it’s your home, you’re cooking a plant-based meal for us. Let’s say I’m coming and I’m like, Jeremy, man, I would love to get down with those impossible burgers. I just can’t brother. It gives me the heebie-jeebies. Do you think you can build a piece of chicken on the grill for me or an egg or some other thing?
We find a way, and you’re going to build the thing [00:20:00] you’re doing around what you are most comfortable with, what serves the most people. School, work and society is built on that same idea as it should be. We cannot hyperspecify for every single person who walks through our door, but we also have to be willing to specify when those people walk through our door.
So if I’m throwing a dinner party as a proud mediator, I’m going to probably grill up a bunch of chicken, but if I know you’re coming, I’m going to make sure you have an impossible burger, gluten-free bun, whatever the heck you need. I’ll even let you sit at our table and eat.
Dr. Sharp: Oh, my gosh. You are so gracious.
Dr. Matt: It is inefficient to plan a million different individual plans, so we’re allowed to plan for the middle as long as we’ve built in the flexibility to adapt when a unique case walks through our door. And so that, to [00:21:00] me, is what neurodivergent-affirming is all about.
Dr. Sharp: That’s fair. I think both of those examples, my veganism notwithstanding, it gets at this idea that I’ve heard it described as just the idea that we’re acknowledging that the vast majority of circumstances, places, environments, processes in our U.S. culture are geared toward the middle and neurodivergent folks is not that there is anything “wrong” or anything like that by any means, it’s just a mismatch between how their brains work and the environment that exists in the majority of our culture and the majority of spaces, much like the 610 individual, they’re going to have a hard time in most cars.
Dr. Matt: And there’s this idea here [00:22:00] that is a fundamental tenant of the neurodiversity movement is that differences aren’t deficits.
Dr. Sharp: Yes.
Dr. Matt: We tend to see people through the lens of this idea that, why are you different? Why is this harder? I don’t know a single person on this planet who would choose to have ADHD. It has some real strengths, but it makes a lot of things a lot harder. All the parents out there who are trying to push their kids into the gifted program; giftedness as a neurodivergence comes with a lot of downsides in addition to its incredible strengths.
I do a whole talk about pushing back on the myths of being gifted and my favorite one to say is oh, you’re so lucky you have a gifted kid, and every parent in that room bursts out laughing, and they’re like, oh my God, if only they knew. I’m like, exactly, if only they knew. It isn’t some [00:23:00] greased skid path straight to Harvard, it’s a psychoeducational emotional struggle.
Dr. Sharp: It’s interesting that you say that. I want to go back to the thing you said about nobody would choose to have ADHD and yet, I think there’s a lot of discussion and experience in my community, which is neuropsychologists and psychologists doing testing, it seems like a lot of folks, kids, adolescents and adults want to be identified as neurodivergent in some way. Can you speak to that at all? Does that match what you’re seeing, if not, how do we navigate that?
Dr. Matt: The culture shift is real around this. The conversations we’re having about this are, it’s out in the open now. It’s not this secret thing like, [00:24:00] hi, don’t tell anybody, right now, kids are on TikTok, this is my favorite ADHD content creator. As a member of that community, I’m like, yes, oh, it’s so cool that this thing is out there now. That makes me very happy.
I tend to be of the mindset that, if I’m going to miss, I want to miss by overincluding people, not overexcluding people. So if there are a few kids out there who think they have ADHD who don’t, they’re still going to benefit from the structures and systems we would use to support ADHD learners like emailing homework home. That’s just a good idea. Sending reminders to that kid, that’s just a good idea.
The structures that we can put into support neurodivergent kids [00:25:00] remind us that the best practices in special education are just the best practices, full stop. Everyone benefits; so what do we have to lose? The only thing I would be worried about would be having a kid who’s on medication, who doesn’t need to be, that’s why we’re having a medical professional look at that to make sure we’re not missing that side of things.
Dr. Sharp: Of course. I do worry about the overpathologizing but that assumes that you’re giving diagnoses that don’t necessarily fit and you’re right, that a lot of interventions that we talk about are just helpful for people independent of diagnosis, right?
Dr. Matt: Yeah.
Dr. Sharp: And that’s fair. That’s a great point. [00:26:00] Before we leave that topic, I would love to hear how you approach the most of situations. I’m guessing you’ve run into situations where folks come in, kids or adolescents, and they are maybe overidentified with some diagnosis or neurodivergence, and you maybe have to have a conversation around, I don’t think this is really what’s happening for you, but maybe it’s something different. How do you approach those conversations when they come up?
Dr. Matt: I think it’s helpful to ground these conversations in what I like to call the big three: frequency, intensity and duration. Everybody has moments where they’re down in the dumps; how often is that happening? How intense are those feelings and how long do they last? Because there’s difference between I’m in a funk for a few days and I’m clinically depressed.
Everybody, especially kids who are growing up and their brains are [00:27:00] rapidly changing, have moments of executive dysfunction. It’s not uncommon to forget what your mom asked you to buy you at the store or to forget to clean your room or to lose your car keys. Basically, all humans do that, but how often does that happen? How intense is the forgetting and how long do those things last?
To me, the biggest marker of true ADHD is the emotional stuff that, I didn’t feel like they told me about that growing up, ADHD is very much as this executive functioning, you can’t find the things, you’re spacing out, you can’t keep your focus, it was very performance-based.
Russell Barkley’s team at University of South Carolina to Lawrence Fung and his team at Stanford, where these researchers show one of the biggest [00:28:00] symptomologies of ADHD is the emotional side; the rejection, sensitivity, dysphoria, the impulse of anger.
That’s the stuff that when I probe these questions with these kids, I’m like, sometimes you forget things and sometimes you lose things, that’s okay. We’re moving along the diagnostic trail. Tell me, do you ever have this emotional symptom?
And that’s so local, oh, gosh, no, that doesn’t happen to me. That doesn’t mean they do or don’t have ADHD, but it means that we are approaching these questions from a place of diagnostic nuance that, and no insult to TikTok here, that TikTok just can’t handle. We’re always going to have a job, but it’s cool that these kids are driving these questions now.
Dr. Sharp: I agree. Ultimately, a lot of folks demonize TikTok. I don’t love it by any means. I think the research is [00:29:00] showing, as far as we can tell, fully 50% of mental health information on TikTok is incorrect is what I’m saying.
It’s not great, but I do like that it’s increased the awareness of mental health and maybe decreased the stigma and ultimately leading more people to our offices, hopefully, so that we can work with them on affirming accurate way.
Dr. Matt: I like to call that phenomenon fence posting. Instead of having to start my client from scratch, I can take the information as a fence post and lead that fence in a different direction.
I had a kid say to me the other day, it’s like, I’m pretty sure I’m autistic because both of my parents are in IT. Okay, so there’s a common perception out there that a lot of IT professionals are autistic. This kid who was very neurodivergent was like, am I autistic because of [00:30:00] this?
I’m like dude, it may not be that simple. Your parents both have neurotypes and that genetic thing made you, let’s explore those questions, but once again, correlation not causation. I’ve got autistic adults in the restaurant industry, in law enforcement, in architecture, in child care, in education and in mental health so it’s not a directionality thing, it’s a, are these things co-occurring.
But now I don’t have to start that conversation at zero, I can take what my client knows and gently direct them to a more factual place, which is perhaps […] psychology thing I’ve ever said, oh, that was a very […].
Dr. Sharp: That was really good. I like the term fence posting too. I’m going to take that and work it into many conversations. Let’s talk about [00:31:00] the actual concrete tip strategies. People love that stuff. You specialize in this; neurodiversity-affirming practice.
There are several aspects of the client experience that we could touch on that we may not be thinking about. So maybe we start with a website. You brought that up as a place that we could be more affirming. So let’s start there.
Dr. Matt: So one of the things that we unwittingly do is we all end up doing things that are more ableist than we mean them to. There’s a difference between intention and impact here. We may not intend to be ableist but the impact of our actions, if it’s ableist, is that we’re still excluding people. So both of those things [00:32:00] can be true.
The reason I started the conversation there is, is your website designed for people of different ability levels and neurotypes to navigate? I have a call, she and I were just talking about this. Her website is gorgeous. It’s like a Pinterest board come to life. It’s amazing but all the links are hidden in the flowers and stuff that are on this beautiful website.
I was like, hey, as a person who loves beauty and design; top-notch, as a neurodivergent-affirming person; you’re missing the mark here because if I’m ADHDer, I’m looking at your website and I don’t see that link, here’s how to book, I’m going to navigate to the next page. I’m confused and lost.
[00:33:00] What I’m seeing a lot of people do now is having a plain text version of their website that you can click to, that strips out all the pretty stuff that makes us stand out from the other therapists to like, book me, my rates, here’s my Calendly, go. It’s like there you go.That’s helpful to people who are overwhelmed by visual stimuli or people perhaps who have some visual impairments who just need to stripped out all the noise and just the facts, mam. Those are little ways we can be neurodivergent-affirming.
We also want to allow our clients to give us their backstories in multiple different ways; maybe it’s an intake Google form you just fill out; a lot of people can do that. My colleague, Gordon Smith, he’s an amazing therapist for the neurodivergent [00:34:00] community. He allows people to just do a voice memo, just click record and just vomit the information to him.
Then he sends that through an Otter, the Otter does voice to text, he gets the same content but it’s a little bit easier for people to do that. I don’t know about you; I hate filling out forms online. I find it very great.
Dr. Sharp: It sucks.
Dr. Matt: I’m seeing people use more click down menus like this or this; you’re lowering the barrier to entry by having multiple ways in. I think that helps everybody do better.
Dr. Sharp: Yeah. I really like that, to think about that voice memo idea. And to your point from earlier, you’ve said the special education recommendations are good for everybody; I think that’s true for website design too. Your website should be [00:35:00] simple, easy to navigate, big buttons, clear calls to action and that kind of thing. That’s going to benefit everyone not just neurodivergent folks.
Dr. Matt: That idea, that the best practices in neurodivergent people are just the best practices. Have you ever seen that cartoon, it floats around the internet where you’ve got, it’s like a wintry day and all the kids are waiting to climb into the school, the janitor is shuffling the stairs and the kid in the wheelchair is saying, hey, can you shovel my ramp? The guy’s like, as soon as I’m finished with the stairs, son. Well, if you shovel the ramp, everybody can get in. Is it that’s simple, because maybe it’s just that simple.
Dr. Sharp: I’m mind blown, what? It’s so true, we get wrapped up in all these [00:36:00] nuances and “unique” accommodations, but it really, most of the time just works for everyone and it’s just fine.
So started with website, you dipped into the scheduling process and onboarding process. Are there other ideas there to be more affirming?
Let’s take a break to hear from our featured partner.
Y’all know that the BRIEF2 has long been established as one of the leading forms for measuring executive functioning in children. Now comes the latest addition to the BRIEF-2 to family, the BRIEF2A. This update will allow you to use the gold standard in executive functioning to assess adult clients. You don’t have to wait, it’s available for pre-order right now. Learn more at parinc.com/products/brief2a.
Y’all know that I love TherapyNotes, but I am [00:37:00] not the only one. They have a 4.9 out of 5-star rating on trustpilot.com and Google, which makes them the number one rated electronic health record system available for mental health folks today. They make billing, scheduling, note taking and telehealth all incredibly easy. They also offer custom forms that you can send through the portal.
For all the prescribers out there, TherapyNotes is proudly offering ePrescribe as well. And maybe the most important thing for me is that they have live telephone support seven days a week so you can actually talk to a real person in a timely manner. If you’re trying to switch from another EHR, the transition is incredibly easy. They’ll import your demographic data free of charge so you can get going right away.
So if you’re curious or you want to switch or you need a new EHR, try TherapyNotes for two months, absolutely free. You can go to thetestingpsychologist.com/therapynotes and enter the code “testing”. [00:38:00] Again, totally free, no strings attached. Check it out and see why everyone is switching to TherapyNotes.
Let’s get back to the podcast.
Dr. Matt: This is the thing that I struggle with a lot, I would ask you here if you feel comfortable sharing, what’s your cancellation no-show policy?
Dr. Sharp: Pretty standard, for testing, it’s 48 hours. We ask people to cancel 48 hours before the appointment or we charge the fee.
Dr. Matt: That’s very similar to mine. I sometimes go back and forth on this because I do think structure and accountability are good tools for the neurodivergent community, we need to give them those things. Also, there’s something that just feels fundamentally icky about taking people who have trouble with [00:39:00] scheduling and time management, and punishing them financially for not attending a thing.
It’s like, who is this balance. It’s different because I do more therapy so it’s the hourly block that’s easier to risk. This cracks me up, I’ll tell my kids, I’m like, if you missed the appointment, if you can reschedule with me this week, I will charge you.
Dr. Sharp: That’s cool. We do the same thing; if you can reschedule within the same week, we’re happy to do that.
Dr. Matt: It’s become a much more affirming practice for me. Yes, our time has value and I don’t love charging people when I’m not seeing them, also, I do need to keep my lights on; it is a business.
[00:40:00] We use TherapyNotes for our EMR and there is every reminder short of skywriting. It’s been like email, text alert, go on your Google Calendar and I still have people forget, but at least I know I have covered my bases.I found booking this website with you very neurodivergent-affirming, you send me a lot of reminders. So I’m up, there’s the thing, and it’s on my calendar, and I got a reminder yesterday, I got a reminder today, so I’m not going to miss this session. Sometimes you book a podcast and they’re like, cool, I’ll see you in November, and it’s just crickets. Are you still alive?
Dr. Sharp: That’s a good point. I go back and forth on the reminders. Honestly, I’m like, is this too much? Is this overkill? I’ve never been annoyed myself by too many [00:41:00] reminders.
It’s always good because it goes the other direction too, you were alluding to with the podcast. It also makes sure that whoever you’re scheduling with has it on their calendar; you didn’t misunderstand or mishear, write it down wrong. So it goes both directions. I think it keeps both people accountable.
Dr. Matt: Absolutely.
Dr. Sharp: What do you think about self-scheduling? I know this might be a little bit different for therapy versus testing, but there are a lot of testing folks out there that will experiment with self-scheduling. How does that fall on the spectrum of affirming?
Dr. Matt: When I worked in a group practice, when I was getting my hours for licensure, we had self-scheduling through that website. Largely, it was a good thing. I pushed for [00:42:00] a way to schedule the clients for them because I found that sometimes you do a session and you’re like, great, I’ll see you next week. And like cool, and then they leave, the thought immediately goes out of their head.
But hey, listen, I’ll just put that on the schedule for you right now, click, click, boom, which is what I can do in TherapyNotes; that’s easy.
Dr. Sharp: Yes.
Dr. Matt: I only had one guy ever misuse it. He booked himself seven times in a week for me. A very hypomanic guy with a history of compulsive therapy use and hoarding behavior. It was the kind of case you want to talk about in graduate school, like oh, this fascinating case, but in terms of like, that’s a lot of that.
So I called him, I’m like, listen, I can’t see you 7 times. He said, but you had availability. I did, that’s true. [00:43:00] I have many other clients who haven’t scheduled yet. He’s like, it’s not my problem. So that balance is…
I would love nothing more than to send all of my clients to a secure website and say, hey, definitely want to see you next week, here’s my availability, fill it in; because then that puts the client in the driver’s seat and has you and I do more of the clinical work using our actual skill rather than spending a lot of time confirming and reconfirming appointments with families, which is just a lot of drudgery. I’ve not found a solution I like yet, but I would be absolutely to one should it present itself.
Dr. Sharp: That’s fair. I think I’m in the same boat. What about paperwork? Anything that we need to consider with our paperwork? Your face says yes. I can’t wait.
Dr. Matt: I sat on a panel [00:44:00] last year at a conference where we had the conversation about is not taking insurance neurodivergent-affirming.
Dr. Sharp: Oh, wow. Okay.
Dr. Matt: Fascinating panel. People got very passionate about it. Like a true mental health professional, I talked out of both sides of my mouth. I’m like, here’s the good stuff, but here’s also the bad stuff. A lot less paperwork, a lot less oversight, a lot less stuff you got to do.
We create super bills, I send them to your insurance company, it’s easy for me to sign up as a non-network provider. So they know I exist. I think I’m not networking like Aetna, Blue Cross, two other ones; that’s sure. I’ll do that for my clients.
It also pushes us in a way that therapy and testing should not be for the 1%. If I’m asking someone to pay out-of-pocket to either full stop or to hopefully getting reimbursed at some [00:45:00] point, I am cutting the number of people I can serve in half.
I think that paperwork thing is, I’m trying to get the most important information up front and use my EMR to fill in information as I go. That’s a cool feature in TherapyNotes where I can add in, oh, I just learned about their religion, or I just learned about their family history, or I didn’t know that they were arrested when they were 19 for drunk driving.
I’m going to add that into the file now vs you’ve got to fill out this four-page packet of information in my waiting room, which you may not want to do. You may not feel comfortable doing. If you’re dysgraphic or dyslexic, you may not even be able to do so. I think that nimbleness, that flexibility is always going to be the name of the game there.
Dr. Sharp: That’s reasonable. Let’s move to the [00:46:00] clinical process a little bit more. This is where it gets really interesting. I’d love to talk about strategies for client interaction, let’s say, interviewing or intake, how can we be more affirming in those practices?
Dr. Matt: I think the biggest thing I have found, and it’s a thing I ended up having to say to parents a lot is you have to understand that this therapy isn’t always going to look like therapy. I cannot tell you how many sessions I’ve done with clients over the years like my nerdy neurodivergent kids where our therapy session per se is them talking about the Star Trek fan fiction they wrote, they’re showing me the link [00:47:00] on the website, and it’s absolutely a thing.
So the parents were like, you didn’t get anything done today. You didn’t work on their ADHD today. It’s like, you’re not wrong, however, let me gently say that this kid trusts me more today. This is a kid who showed me their world and I opened that door and went with them.
I went to Mordo with them. I didn’t just say, excuse me, we’re supposed to be on the path to Elden Wood. Sometimes, you’ve got to do things that are very atypical to get these kids to open up to you.
A lot of times with neurodivergent people, you can’t walk through the front door. In an ideal therapy session, it’s like listen, we need to talk about your childhood. [00:48:00] Okay, but a lot of neurodivergent people have built a lot of walls and boundaries, so sometimes you got be willing to go through the side door, or you’ve got to be willing to address things in a more roundabout way, and trust yourself as a clinician to guide the train there, but also trust your client that when they’re comfortable, they will go there with you.
Every so often when I see a neurotypical client, I’m reminded that therapy is never easy, but it can be much easier. With some people, it’s like, oh, you’re just here to talk about. Oh, great. By all means, tell me about your husband. I’m here for it. I put my hands behind my head and I kick my feet back and relax.
You’ve got to be willing to get on the wavelength of the people you’re seeing, and that [00:49:00] means moving away a little bit from the therapist as God model and see the therapist a collaborator model. That’s hard for a lot of our colleagues. We got these fancy doctorates for a reason. We want to be the boss.
Dr. Sharp: Right or be helpful. I think that’s where I personally get wrapped up. Back when I was doing more therapy is, if we got off the plan, so to speak, I would have these concerns about not being helpful. I’m like we’re not doing anything; we’re not being productive.
Over time, I’ve let go of that as much as I can, but it just speaks to that point. It’s okay to do some joining and chatting about things that may not immediately be productive.
Dr. Matt: And isn’t it fascinating to think about what does [00:50:00] productive mean for our clients? One of the many reasons I don’t take insurance is that I got really tired of an insurance company saying to me, you got 12 sessions to fix this kid’s OCD. So I have to get a lot done. I have to move quickly.
This work, it’s an art and a science. Sometimes you got to do a session about the drama in middle school so your kid knows they’ll listen to you, or you talk about the Star Wars Build that they’re doing in their LEGO set in their basement. Those things are not by the manual; the classic CBT approach to OCD, but there has to be room for us to do stuff like that with our clients or we risk losing them and they fall out of therapy.
One of my kids that I see, [00:51:00] she has an auditory processing disorder, she finds the telehealth with the video very overwhelming. So we talk on the phone more often than not, and when she’s having a bad sensory day, we text, we do our sessions via text. It’s a little inelegant, but it gets the job done. It’s meeting my client where she is and then doing what I can from that place.
Dr. Sharp: That seems to be the theme here is flexibility, adaptability and being willing to go off script a little bit and do what the client needs. It seems like a no-brainer, but it’s harder to put into practice.
Dr. Matt: Really should be a no-brainer.
Dr. Sharp: Sure. Let’s talk about the testing process. I know you do primarily therapy, but also have a lot of experience with testing. Maybe I would lump the environment into [00:52:00] that area as well. Maybe we tackle that at this point.
Dr. Matt: My mentor, Dr. Michael Cassano, he was the guy who taught me how to test kids. We didn’t use that language at the time, but very neurodivergent-affirming. He’s like, I used to work at a therapeutic school for kids in Maine, and a lot of times kids would be so full of energy, they couldn’t sit in my testing room, and we would just walk the track.
He’s like, so I had every question for vocabulary and every question for similarities memorized because I could just recite those questions. He’s like, I knew enough that it was a 2.1 or 2.0 answer. You can’t do everything like that, of course, you need to get to see matrix reasoning to do matrix reasoning, but there’s a lot of them you can do playing to that kid’s [00:53:00] physical, emotional, sensory needs.
If you read my reports, it’s like we conducted visual puzzles with the client under the table because the client said they were overwhelmed. So I was like, here’s the thing, tell me the answer, I’ll write it down and then flip the page.
Is it what the manual says we should do? No, it isn’t, but the manual is built to serve typical kids and these are not typical kids. I’m not going to let the kids look at the answers, I’m not going to give a kid with auditory processing disorder more hints, you only need to choose between two answers, not five. That’s inappropriate but the structure of how we approach the testing process and to your point, the physical space, I think we have a lot of adaptability in that, and that’s really cool.
[00:54:00] Dr. Sharp: Definitely. I’ve heard some really cool stuff, just internet, Facebook groups and that sort of thing about even like lighting in the waiting area, lighting in the testing area, not getting away from fluorescence, trying to do as much.Dr. Matt: That won’t work, I’m telling you it’s forever.
Dr. Sharp: Yeah, little things like that; the magazines in the waiting space, the type of furniture that you’re looking at, even the color palette, that kind of thing. Having a testing room that is safe enough where kids can move around and furniture that will accommodate hanging upside down or feet up on the couch or whatever it may be, little things like that that make a big difference. I wonder if that matches your experience as well or if you have other thoughts.
Dr. Matt: It absolutely does. [00:55:00] I’m thinking about a testing case I did once with a very anxious kid on the autism spectrum. He was really into law enforcement. He’s having a lot of trouble providing verbal answers to me, so I said, what do police officers do when they need to talk to each other? They talk on a walkie-talkie.
I was like, I don’t have a walkie-talkie with me, but what if you give me all your answers; come back breaker. Come on this is a hot cop. He locked into that. So he gave me all of his answers via this invisible walkie-talkie.
And then around halfway of the session, he was like, can I bring out my stuffy? So now he’s got the stuffy, sometimes the stuffy is giving me the answers and sometimes he’s talking on the microphone.
If you’re going to work with an autistic person, I’m going to get the best version of that person through the things they need to do to survive [00:56:00] rather than saying, excuse me, in the testing process, you sit still in the chair, you can have no toys or fidgets or water, you’re going to sit there and you’re going to answer the freaking questions. There aren’t that many people who can do that.
I’m sitting here doing this podcast with you, I’m having sips of my coffee because my day started very early this morning. If you were like, excuse me, we don’t have beverages during our podcast, then I would be less effective as your podcast guest.
I think as long as it doesn’t detract from what we’re here to do, which is answering the questions and figuring out how this kid’s brain works, then I give my clients a wide swathe of what they’re able to do in those spaces, including just pacing around the room as long as they’re not looking at the answers over my shoulder.
I have had a few kids try to do that. It’s like, oh, I’m just… Like when you were in middle school and you got up to [00:57:00] sharpen your pencil and you’re like, what have you got for number seven, -3, interesting. Not that I ever did that, of course.
Dr. Sharp: Never, me neither. For sure. I love that idea. I feel like we do a lot of testing with kids and sometimes adults not sitting where they’re “supposed to sit”. There’s a lot of on the floor, moving around, walking, standing, jumping, all those things. That’s great.
Let’s talk about the report. Are there neurodiversity-affirming writing styles or even text layouts or considerations with the report that we could keep in mind?
Dr. Matt: What I usually do is do a feedback session with my client and give them a one pager with bullet points [00:58:00] that says, here are the things you need to know based on this report because there’s a lot of jargon, there’s a lot of unnecessary stuff that we … If I’m doing Doc to Doc, I know you need to know that these pieces of information.
I’m basically saying here are the most important recommendations. Here’s the diagnosis. Here’s how I got there. Here are the strengths and weaknesses. Here’s how you talk about this to your HR representative, to your school principal, to your school psychologist.
When I do the report itself, I usually make two versions. One, I’ll do my standard Times New Roman size 12 font, but there are special fonts that you can download as a macro for word that are more readable for the dyslexic community; start bold and [00:59:00] fade. What that does is it re-engages the optic cortex every time a word starts.
Dyslexic people have found that it’s significantly easier for them to read. I might make the font size bigger and have one and a half spaces. So now there’s a little bit more visual space because what do I care if I’m just emailing a PDF copy, I’m not killing any trees this way. So I’m sending my client a copy that’s more readable to them.
I think even asking that question to your clients; are you somebody who listens to podcasts at 1.5x speed? On your Kindle, what sizes are the words? Asking those questions tell our clients we care about who they are and what their neurodivergent experience is for them.
[01:00:00] Asking those questions align us with what they might need. When we know what they might need, we’re more able to give it to them.Dr. Sharp: I love that. Where in this whole process are you asking those questions? Is it happening along the way? Is it at feedback?
Dr. Matt: I try to remember to ask it in the onboarding process. When I finish the testing process and I do my feedback session, when I’ve created the port of there, is there anything I can do to make this report more accessible for you?
I had a client tell me this because an open-ended question for somebody who doesn’t know what they need to know is potentially problematic because she’s like, give me a few more options. What is it? How can I make this more for you? I don’t know.
Can you [01:01:00] come over to my house and do it in interpretive dance? Can you make it a graphic novel? You have Morgan Freeman narrate it? I don’t know. So I started talking about like fonting, spacing and stuff like that; making it more concrete.
Dr. Sharp: That’s fair. I’m thinking about this right now, so I don’t have the answer, but are there different file formats that are easier to go text to speech? Is it Word better for that or a PDF or some other format I’m not thinking of, just little things like that?
Dr. Matt: And I don’t know the answer to that, but that’s a thing we could absolutely figure out. And that’s the beauty of all this, because we get to learn and grow along with our clients. Like Maya Angelou always said, do as well as you can until you know better and then do better.
Dr. Sharp: It’s a great way to put it. [01:02:00] I appreciate you saying that. Just to zoom back out a little bit, talking about this stuff can be pretty fraught for clinicians. It’s one of those areas where a lot of us are afraid of doing the wrong thing or making a misstep or saying something offensive or not doing something correctly.
It’s a good reminder that having a perpetual learning mindset or growth mindset is really valuable and it’s okay to keep learning along the way. You don’t have to have it all figured out from the very beginning.
Dr. Matt: I think that kind of intellectual humility plays very well with this population. My clients constantly ask me questions that constantly challenge me on stuff. Sometimes it’s like no, I do this for a reason, and here’s why; I can show my work and [01:03:00] justify my choices.
Sometimes I hang up the call and go, damn, do I need to do this better? I can’t always fix those problems, but I can absolutely hear them out and think about where do I go from here?
Dr. Sharp: I think that’s the best that we can do; that’s the best we can ask for. At least consider it, see what could be different and do our best.
Dr. Matt: Absolutely.
Dr. Sharp: We’ve talked about a lot of different things. As usual, there’s much more that we could talk about, but I appreciate this. It’s a broad perspective. We touched on a lot of different areas and topics that will be helpful for folks. If they do want to either reach out or learn more or get more information from you, what’s the best way to do that?
Dr. Matt: I have two primary online presences. The first is our therapy practice, which is, [01:04:00] The Neurodiversity Collective. That’s myself and my colleagues. We see people from all over the country. You can’t really do testing virtually, but we can do therapy virtually. So as I say to people, if you think I can help you, you contact the Neurodiversity Collective.
If you think I can help your organization, whether that’s a school or a college or a business or your community organization, then you contact drmattzakreski.com. That’s where I do my speaking, my consulting, my training. I try and keep those two businesses separate because it’s two different parts of what I do.
Dr. Sharp: That makes sense. I do the same thing. I really appreciate it. Thanks for coming on. I know you do a lot of this stuff and I’m appreciative for your time and willingness to dive into a pretty important topic. Thanks for being here.
Dr. Matt: You created the space. It’s so cool to be able to [01:05:00] talk doctor to doctor in this way and talk to another mental health professional who really understands this stuff. I feel like a lot of times, I’m talking to educators and parents, which is so important, but it’s really cool to get very high level and stay very high level. I think we both got to learn something from each other and I’m sure the audience will learn a lot from us too.
Dr. Sharp: I totally agree and certainly hope so. Hope that maybe we’ll talk again soon.
Dr. Matt: I would love that.
Dr. Sharp: All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out.
If you like what you hear on the podcast, I would be so grateful if you left a review on iTunes or Spotify or wherever you listen to your podcasts.
If you’re a practice [01:06:00] owner or aspiring practice owner, I’d invite you to check out The Testing Psychologist mastermind groups. I have mastermind groups at every stage of practice development; beginner, intermediate and advanced. We have homework, we have accountability, we have support, we have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the details at thetestingpsychologist.com/consulting. You can sign up for a pre-group phone call and we will chat and figure out if a group could be a good fit for you. Thanks so much.
The information contained in this podcast and on The Testing Psychologist website are [01:07:00] intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric or medical advice, diagnosis, or treatment.
Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.