Episode 33: Supervising Neurodivergent Clinicians: Understanding Executive Functioning, Interest-Based Nervous Systems, and Learning Styles with Kara Cruz

Welcome back to Your Clinical Supervisor’s Couch podcast, and I’m your host, Kayla Das.

In today’s episode, Kara Cruz, licensed marriage and family therapist will share strategies for supervising neurodivergent clinicians from understanding executive functioning, to integrating various learning styles.

Hi, Kara, welcome to the show. I’m so glad to have you here today.

Hi. Thank you for having me. It’s good to be here with you.

Kara, before we dive into today’s episode, please introduce yourself and tell us a little bit about your practice and your clinical supervision journey.

I am a licensed therapist, a marriage and family therapist from California. I’m also certified in perinatal mental health and newly in the last year EMDRIA certified therapist. So that’s, that was very exciting.

I’ve been doing clinical supervision since 2021 and started my practice, before that, in 2019, I worked in community mental health for many years and always knew I wanted to go into private practice. And so as soon as I became licensed, I already had everything lined up. Went into private practice, and I had a couple former directors and managers from different agencies that said, hey, when you hit that two-year mark and you can do clinical supervision, we would love to have you so apply.

And so when that two-year mark hit, I reached out, submitted applications so that I could get onboarded to do clinical supervision. So I did supervision for one is a local nonprofit and I’m still with them and I also did our county mental health as well. And had a good experience with both. Met some really great new. Therapists and helping them along the way. But I ended up after a couple years just sticking with one place because I wanted to grow other parts of my business and I wanted to, with my ADHD brain, I can burn out really easily. So I have to really be mindful of how many clients I carry on my caseload, as well as how many people I supervise. Ethically, what’s responsible for me to do so that I can do a good job.

So I stuck with one of the organizations. I’m still with them. I carry a small group of supervisees trainees, who I work with, and I absolutely love it. And I also co-facilitate, co-host, co-found, a free resource for clinical supervisors called Supervisor Support Circle. Another therapist and I created it. We loved working together and forming different community groups locally in our area, and we found that there was a need for clinical consultation that was surrounding clinical supervision.

We had our consult groups that we went to for regular client care, and we just found that we were messaging each other, reaching out to other supervisors for questions, little things, form questions or timeline questions. And we said, we need a monthly accountability hub where we just can come every month and present cases.

Because clinical supervision consultation is different than your regular peer consultation. So I currently have three people I supervise right now, so it’s on the lower end, but it works really well for me with my client caseload.

I love that. So let’s get into the main topic today. Can you explain how ADHD shows up in clinicians themselves and why understanding interest-based nervous systems is essential when it comes to providing clinical supervision?

Yeah. So first I want to say that many people, especially the adults I work with have not been formally diagnosed with ADHD.

So as therapists, when we start to learn about mental health, we start to see trends and traits within people we know close to us. Not that we’re diagnosing them, but things and you have more insight. It’s different than prior to your training. And a lot of times that translates into yourself, you start to learn more about yourself.

And there might be some who aren’t formally diagnosed, some who may think that they may have some kind of ADHD or attention condition, or some who have been formally diagnosed with ADHD. So I just kind of want to speak to that, that even if you’re not formally diagnosed, you think you might have it. You are in the process. This can apply to you two.

But as supervisors, it’s really important to know that, they can be all on or all off. And so their nervous systems are much different than typical person’s nervous system. So a lot of the comments that you’ll hear about somebody with ADHD is often that they were managing that really well.

They were like going, getting things done really in a flow. Just working really hard and then all of a sudden it’s this other end of the spectrum where they shut down, they withdraw, they isolate, they’re burnt out, their energy’s different, and it can almost look something like a depressive episode. It can look like almost like a bipolar presentation, but really what it is it could be some sort of burnout. We’re on, then we’re off. And so when we’re on, we can be really on and hyper-focused. When there’s something that interests us or engages us or pulls us in, that pulls us almost into like a flow state. We’re excited. But even in those states, we can overdo it and burn ourselves out and then go on the other end.

That’s really helpful. And being able to conceptualize how to work with supervisees who have ADHD or neurodivergent. So when we’re thinking about supervision, what supervision practices best support executive functioning challenges? Say, like time management, task initiation or overwhelm for clinicians with ADHD.

Yeah, I’m going to just first back up because I don’t think I fully answered your question. My ADHD brain needs to stay focused, but I just want to look at some traits that we might see in these clinicians other than like the on-off, the nervous system is we can see a lot of inconsistent energy, which I did mention difficulty with their documentation. Time blindness, losing track of time. All of a sudden, they were supposed to go into a meeting and they got hyper-focused on doing a treatment plan. Perfectionism, intense self-criticism. But many of them are highly intuitive, creative, engaging, charismatic, have a lot of positive traits as well. But if you’ve seen some of these traits in some of the people you work with not that we’re going to diagnose them, but just some of these tips might be helpful for you, but practices that involve structure with flexibility. So we do want some boundaries and structure, but we do want to be flexible.

Clear priorities. Even down to making lists of what has to get done today, what should get done, what would be nice to get done, breaking down things. Instead of having a long list, these are your three priorities for the day instead of here’s your laundry list of everything. Doing body doubling sometimes for accountability can help. So quietly working next to somebody and just checking in with them can be helpful. Also being mindful that interruptions can be hard. Transitions are really hard for people with ADHD because once they get really into that flow state and hyper-focused, and it could be on something that needs to get done, like their documentation, their treatment plans, when there’s constant interruptions, questions, the phone ringing from other people, it can really be hard for their system to get back into the groove and sometimes they can even go into a shutdown.

So having the boundaries of, here’s an hour. Go ahead and go work on this. Stay focused on this. Set a timer. Take your break. Put a note on your door. Don’t answer the phone. Put your phone on DND That’s really important.

And sometimes in work cultures, that’s almost not accepted because it looks like you’re not creating a welcoming open space. But really that’s essential for somebody with ADHD to stay focused and to get things done.

Oh, that’s really good to be able to conceptualize that. How do diverse learning styles among neurodivergent clinicians impact how clinical supervisors teach, assign tasks and provide feedback in supervision?

I think it’s important to not assume and have a one size fits all. It’s really important to get to know the person. I’ll give an example, and this doesn’t really involve supervision, but it involves working with children with ADHD.

I remember sitting at an IEP meeting and a lot of the IEPs that the child wouldn’t even be invited to them. So that was problem number one. But in this situation, they actually had invited the child there and it was a very, helpful, careful, team that really wanted to be mindful of the child being present and being involved.

But when it came to setting up some just systems for the child to be successful. I think they were talking about test taking. They made an assumption about the child that they needed to be in a quiet space with no interruptions and take their test. And so they just assuming that was the best thing for them. And let’s write it in. And thankfully this was actually my client, right? He spoke up for himself and he said, actually, no, I like to have my headphones, AirPods, whatever it was at the time, and I like to be listening to music. And they said no. That’s going to be distracting to you to listen to music.

And he said, no, it’s the people talking in the background– because they would put him in a younger class that wasn’t really loud and chaotic, but it was like, just almost like the lack of noise was more distracting. And would slow him down and he would start to zone out. Dissociate a little bit. He needed a little bit of music to keep him in that flow zone. And I was really proud of him for speaking up for himself. And then they looked at me to chime in and I said, some people silence is actually not helpful for them to focus. They need a little bit of like stimulation movement or something happening in the background.

So it’s really important to ask the person about their learning style, how they learn what’s best for them. Another person might say, I need absolute silence. And at a workplace, right? If you’re a clinical supervisor, don’t assume that a quiet workplace is going to be essential and best for your supervisee with ADHD.

Some learn by doing, some learn by seeing, some learn by practicing with gentle guidance. So it’s really important to ask them about their learning style, how they do best and some are going to need a combination of a few things.

I love that. And I think that when we’re thinking about clinical supervision overall, regardless of someone is neurodivergent or neurotypical, understanding that everyone has different learning styles is really important. And when we think of say, therapy, we always are very client centered. With our supervisees it would make sense that we would also be very supervisee centered, that ensuring that we’re connecting what it is that they need to the supervision services. So I love that you highlighted, the learning styles and the different types of learning styles.

So something that I’m actually thinking and let me know if this would be a practical strategy, but it’s literally asking someone, how do you learn what is the best approach for us in supervision sessions?

Yeah. I would be asking them, how do you learn what’s the best approach? That’s a perfect broad opener to get some information. And then if you wanted to get really specific, I would just think of maybe the top one to three tasks. When you’re doing notes and documentation, when you’re taking in information, when you’re working with your client, whatever it is, pick two to three things and say what environment supports you the best.

So they might say when I’m doing my notes and documentation, it’d be most helpful if I had a quiet space in my office and I could wear my AirPods and maybe put a little sign up. I used to put a sign up when I was in community mental health side note and it would say webinar in progress. Because that was the only way that people wouldn’t interrupt me. And that was what the agency was like, do not disturb feels rude. And now I don’t think I would need to lie. Per se. And put like webinar in progress. I could put quiet focus time or something, or notes in progress it’d be fine to do that.

But asking the person what would be helpful for them and picking, when you’re doing notes and documentation, that’s just the norm for you. Maybe you have your headphones on, or you’re in an office with a closed door and you put a little sign up that says, for an hour you have some blocked off time that’s private. Phone calls are put on DND, whatever. When you’re working with clients, obviously that’s uninterrupted time and but what works best for you and how do you work best is really important to ask and maybe just pick one to three things to start with because it can feel very overwhelming to try to hit everything.

I really appreciate that. So what are some key indicators that a neurodivergent clinician is approaching burnout or overwhelm and how can supervisors intervene early and effectively?

There’s many different things, but I would say some things to look out for are overworking hyper-focus without taking breaks. And when I say breaks, just the basic breaks like water, food, bathroom. But also taking just breaks. I call it my un-peopling time. Maybe we’ve done the bathroom breaks and done all that, but we go and we’re therapists, we’re constantly having to be actively listening, fully present. Much of our job, right? We’re in meetings, we’re with clients, we’re teaching whatever we’re doing that part of our brain is fully engaged almost all the day. And even though we’re maybe just sitting. Sitting in a chair the whole day, it can be very taxing. So it’s really important to, like I said, I have my un-peopling time where it’s quiet time where I’m not having to fully be on my brain, can check out for a little bit. And I’m not needing to be social. I’m not needing to interact. I don’t need to actively listen. I can just be present. And so maybe I’m doing something like organizing my calendar is still working. If it’s part of the workday, there’s something I can be doing that lets my brain rest if it’s not a full break.

Another thing that on the other end of the spectrum, you can see withdraw. So somebody who’s withdrawing, missing deadlines, shutting down, they can’t even get started. Task initiation problems missing deadlines, avoiding work altogether. Missing work on Mondays, because they’re just burnout from the weekend. So you can see this overworking like this on where it’s hard for them to come out of that. And then you can see a shutdown where it’s hard for them to turn back on. And I’d be paying attention for both of those things because we get praised for the being on all the time. Go work. Don’t take a break. Get all your checklist items done. See as many clients as you can. And that is a road to burnout.

Oh, I appreciate that. How can supervisors create an attuned and supportive environment for neurodivergent clinicians in supervision?

It’s basically thinking of how we show up with our clients. We’re curious, we’re open, there’s no judgment. We show empathy and compassion. We ask questions, we join them. And I think sometimes we forget the way sometimes we interact with our colleagues. Because I would consider when we’re working in a supervisee supervisor relationship, it is a different power in a sense differential, but it’s still a colleague, right?

What I see is sometimes the switch that the person has when they’re present with their clients is different with their supervisees. And these are still human beings we’re working with. And we want to create a space where there’s openness. Somebody feels comfortable with sharing if they choose to. They don’t have to share that they have ADHD if they don’t want to, or that they might be considering that. But we want to just create a space for safety. So just starting out with non-judgment. Curiosity, openness and willingness to learn that will really help to reduce shame.

Now, if we know that the person has ADHD, let’s say that they’ve already shared that information, they’ve disclosed that, then just naming it, talking about it, asking about their experience asking them what’s helpful for them.

What types of I don’t like to use words, symptoms because it’s really pathologizing it. But what are the traits about ADHD that you really love about yourself? What are the things that make it really hard to do your job? Getting to know those parts of that person is really important.

What I thought for a long time when I was in community mental health was, I’m going to just be very blunt. I sucked at my job. I was a terrible employee. I could not stay on top of everything. I could not stay on top of client care. Seeing all my clients and all the documentation, joining all the committees, doing all the other things outside of my job and just my regular life and having a child myself. I worked with kids, right? So it was like spinning all these plates and I couldn’t keep them up. And it was an all or nothing mindset that if I can’t do it all and get it together, then I just suck at my job. And that felt terrible.

And part of me deep down knew because I would be in the room with clients and seeing them light up and seeing change and them thinking, and I’m like, no I don’t suck at my job. I’m good at my job and I do good work when I’m at my best, but when I’m at my worst and I burn out, I’m not very good for my client. And I’m not a very good employee either, and so that created a lot of shame. Spiral. I compare myself to mostly my neurotypical colleagues who, just seemed like they had it all together. They weren’t running late for things. They just looked presentable and put together. I just would look at them and think like, why can’t I do that? How come I can’t get my stuff together?

It’s interesting because you talked about shame and I literally just yesterday when I was listening to the radio. The radio station was actually talking about things that, us as humans feel guilty about. And one of those things is not being able to do at all and how we all feel guilty for doing that. And of course, I think really what they were talking about is the shame of not being able to do it all. And really what you just said. Reiterated that. It’s hard.

And sometimes there’s even unrealistic expectations when we think of working in agencies because really, they’re not even built to be realistic for anybody in some cases. But then for someone who is a neurodivergent clinician, like you said, trying to balance all of these plates and that all or nothing of, if I can’t do it all, I might as well do nothing. I think that’s very relatable.

And then that comparison trap of this person is able to keep up with it but I can’t. But the interesting piece is that comparison trap is that person actually keeping up with it? Are they actually thriving, or is it the perception of that? And I think that’s a challenging place to be in many cases.

Yeah, the perception of it, because probably my neurotypical colleagues were also feeling burned out too and overwhelmed. We were all in the same boat, but their capacity was a little bit maybe wider to handle it or to look on the outside that they could handle it than mine was. My mask would flip quicker or just go into shut down.

I went to therapy, while I was in grad school, that was a requirement, but during COVID was the first time I really started exploring different therapists because we had the virtual world and I could look at finding a therapist. It was a good match for me. I didn’t have to just go to somebody locally.

And I didn’t even know this is what I was doing, but I found somebody who was EMDR trained somatic experiencing practitioner and I can’t remember what her third thing was, but she was the one who really got me out of my head and into my body for the first time. And the only way I could describe to her how I felt is it was I just kept grabbing my head and I was like, my brain just feels like it’s on fire. That’s all it feels like when I think about my work and when I look back, I was in severe burnout for a long time and didn’t even know, like I didn’t want to do anything on the weekends.

I would miss work a lot of times because I just was in shutdown and it was hard to get out of it or avoidance. The Sunday scaries were big for me. Knowing what I know now and I’m not perfect now at it, right? I go into hyperfocus, I can burn myself out. I can get really busy. But knowing and being attuned to my body and what’s happening in my nervous system is so much more helpful. And then being around other people, I purposely surround myself around people who know this, get it, and accept it.

Absolutely. So what practical strategies could supervisors offer neurodivergent clinicians to help them thrive in clinical practice while protecting their energy, creativity, and capacity?

I think there’s a lot of options, but the one I want to start with, I think is attainable that you can do. Like week one. And I started doing this, not knowing is building my schedule around my energy. So I always knew, I found this trend I noticed, like when I first started in community mental health, before I was even a therapist, by Thursday night, I even taught a Thursday night parenting class. By Thursday night. I was like, done, this was the end of my week. I was burnout ready for the weekend already.

And so when I became a therapist, moved into that department one of the things I really tried to do was schedule, and it’s not always possible. I know sometimes see the clients when they have space available and when it works. But I had this taper down approach that I would start. So I’d ease into my week. I wouldn’t do a super heavy Monday. I would load everybody into Tuesday, Wednesday, Thursday. I would give myself transition time in the morning to get in, check my email settle in.

My most creative time for me is like in the morning, 9 to 11. So if I did need to do anything that required a lot of my brain power or creativity, I really try to work that in the morning and then client care midday and really try not to go beyond my threshold.

That’s not always possible in community mental health, but as a supervisor. If you can work with your supervisee on looking at their schedule and trying to build in breaks. Think about, blocking off a half of a day or a full day to just focus on documentation with no meetings is helpful for me because I’m in that zone. I don’t have to transition from client to note.

So thinking about how your week looks, your day-to-day looks can be really key. I try to work around my energy knowing when I’m most energetic, knowing when my energy drops.

Two in the afternoon, I am no good. Like I, there used to be a running joke in my office that like, when I started to get loopy or goofy, they’d be like, uhoh, it’s two o’clock. Kara’s needs her caffeine. And it was just a running joke, but it was true. So once I knew that about myself, I was really careful how and when and what I scheduled at that time. Sometimes it was just doing mindless paperwork, checking when I was a supervisor, like checkbox paper, logging things in, I could have my snack and do it. I didn’t require a lot of brain power, but those types of strategies work. I know my sweet spot for meetings is like three to four a day. Beyond that I start to burn out. So if you have the flexibility to do something like that, do that if you do better with, I would rather load everybody into one day, get it out of the way and just really take care of myself that day and take breaks and then have the next day my documentation day. Do that. Do what works for your energy.

Or if you’re in a community mental health setting where you have less flexibility and kind of control over that, supervisors, talk to your supervisee about that.

Love that strategy and I actually do that as well. So I am a morning person, so anything after around two, three I’m pretty much useless when it comes to anything that takes a lot of brain power. So I really focus on the brain power work in the morning so that in the afternoon I could have some of the tasks that don’t take a lot of brain power.

Anything after four, I’m out completely. Like it is not even worth my time anymore because I am just not there. And I think that knowing yourself is the key of being able to identify. And like you said, not always can you navigate everything that way, but even if you can switch up some things, right? Whether it’s specific clients or specific tasks or again, you mentioned doing things earlier in the week versus later in the week. Of course, that works better for you or doing things later in the week versus beginning of the week if that’s better for you. But really knowing yourself and setting your day up in a way that’s conducive to you.

My Fridays, I would basically try to have everything, client care and all that done earlier in the week. And then my Fridays were makeup day. If a client was out and I needed to catch a client, see them, do parent phone calls and then catch up on documentation. And the end of my day was looking at my calendar and planning for the week ahead. If something looked too chaotic, I could move things around if I was able to. I had extra time to get a task done on my list on Friday. That was like my catchup day, breathe day and eased me into the weekend.

And then starting in the morning and on Mondays, I found that if I was really rushed in the morning at home, trying to get my son to school, trying to get ready, I was very dysregulated to start my day. So I was like, why am I starting 8:00 AM appointments? Because everyone says get it out of the way. That’s much better. That’s much better for them. That’s not much better for somebody who. Doesn’t like to be rushed, isn’t a morning person to begin with. I need to have a good like kind of hour in the morning to get to work, get settled in, check my email, not really be on until I feel settled. And so you have to really work with your nervous system on what works.

If you’re a woman too, or if you have a menstrual cycle, that’s another podcast, right? The cycle sinking, looking at your energy. Even if you can’t do much and have a lot of control around that, just knowing that. Oh, my energy’s dipping. I’m going to need to take care of myself a little extra more, make sure I have snacks. Make sure I get extra sleep the night before. I’m extra hydrated if I don’t have a lot of control over my schedule. Take care of yourself during those times when you’re more vulnerable and you can tolerate less, you know?

Absolutely. Kara, you have a free checklist that you’d like to share. Can you tell us what it is and how it can help listeners?

I do. It’s called Focus on Women and ADHD. It’s a symptom or trait, checklist and resource guide, and it’s close to 10 pages, I believe. The first page is a checklist of ADHD symptoms you can go through. If you’re already diagnosed, you probably know that you have them, but you can go through and see which ones are most prevalent for you or that you struggle with the most.

If you’re somebody who thinks you may have ADHD. It’s a nice starting point. It’s basically the symptoms based off the Diagnostical statistical manual. So it gives you a good idea of is it more inattentive, impulsive, hyperactive symptoms, which you can mark, which symptoms are most are mild, moderate, or severe. You can take a note and this checklist can be for clinicians to use with their clients. It can also be for women.

If you’re not a clinician or a therapist, you can use this just to get a sense of what’s happening and take it to your provider. This is not going to diagnose you, but this is gonna give you an idea of what’s happening. There’s some a questions list where it gives you questions. You can ask a provider if you go to a psychiatrist, your medical doctor, your therapist what are some good questions to ask?

Then there’s resources, podcasts. Books, experts in ADHD. And so this is a workbook that I created that’s essentially helpful for a woman or a therapist or a supervisor. It can be used by all.

Also, you have a live retreat coming up. Can you share what it is and also what it’s about?

Yeah, so it’s in Las Vegas. It’s called Diversify Beyond the Chair. It is myself and five other therapists who have diversified their income streams. We offer other types of services besides the one-on-one therapy.

For me, I’m somebody who runs groups therapy and support groups for women. I also teach therapists how to start their own therapy or support group. We have experts who teach you how to go from being a therapist in the chair to getting paid to speak. And share your wisdom and gifts. We have an expert who talks about how to build your private practice.

Someone who’s talking about how to create CEEs from your expertise if you want to be a CE provider or CE trainer. And so we’re all going to be in Vegas. It’s a retreat. It’s basically, workshop training, very interactive, small group, 40 or fewer participants spots are open and we’re going to be in Vegas for three, four days.

This is very neurodivergent friendly too. We start out, we do our learning. It’s interactive from each of the teachers, I’m one of the teachers, instructors, leaders who will teach a workshop. You do about two a day and then the afternoon is free. So after lunch your day is done.

So you can enjoy Las Vegas, you can go to the pool, go out to dinner, walk around, and it’s not one of those heavy days where you’re in a conference from 8:00 AM till 5:00 PM and then you just burn out and want to go lay on your hotel bed. So it’s going to be a lot of fun. I personally know all the therapists who are leading the retreat. They’re all wonderful, brilliant. I’m excited to go and not just speak, but to actually be in the workshops and learn from them too. So gain that wisdom. So this is going to be in April of 2026. And if you’d want to join, you’d have so much fun. It’s going to be a blast.

Oh, it does sound like such a good time.

To sign up for Kara’s free focus on women and ADHD checklist and resource guide, check out canadianclinicalsupervision.ca/karacruzchecklist,

or to sign up for, diversify Beyond the Chair. Simply scroll down to the show notes and click on the link.

Kara, thank you so much for joining us on the podcast today to discuss how to supervise neurodivergent clinicians.

Thank you for having me. I enjoyed being here and talking to you. I know we could have gone on and on and there’s so many different topics, but I just love sharing what I know and what’s been helpful for me.

And thank you everyone for tuning into today’s episode, and I hope you join me again soon on your Clinical Supervisors couch podcast.

Until next time. Bye for now.