E56 – Triple Combo: ADHD, OCD & Autism + guest Cali Keating

Julie Legg interviews Cali Keating, a neurodivergent therapist based in Barcelona who specialises in supporting clients with the triple combo: ADHD, OCD and autism, and various dual combinations thereof.

Cali explains how OCD, like ADHD, is tied to dopamine and cortisol regulation and how these overlapping neurodivergences can complicate diagnosis and treatment.

The core of the conversation revolves around multiple neurodivergent diagnoses, commonly referred to as “multiple exceptionalities” or “twice exceptional” when someone has more than one neurodivergent condition. Cali dives into the mechanisms and nuances of OCD, especially “Pure OCD” (also known as “Pure O”), which involves intense mental rituals rather than visible compulsions.

KEY TAKEAWAYS

  • OCD affects both dopamine and cortisol regulation, making it not just an anxiety disorder but also a neurological one. The compulsions aren’t just habits, they’re urgent attempts to neutralize biochemical distress caused by intrusive thoughts.
  • Characterised by intrusive thoughts and compulsions used to neutralize distress, OCD is commonly misunderstood. It’s not just about neatness or repetitive behaviours—it’s a neurological survival response, often invisible and deeply distressing.
  • “Pure OCD” involves mental rituals rather than visible actions—this includes rumination, mental checking, or seeking constant reassurance. These hidden compulsions often go unnoticed, delaying diagnosis and understanding.
  • Traits across ADHD, OCD, and autism can appear similar—such as hyperfocus, rigidity, or sensory sensitivity—but the motivations behind those traits differ. For example, hyperfocus in ADHD might stem from dopamine-seeking, while in OCD it may be driven by an obsessive need for certainty.
  • Misinterpreting those motivations can lead to support plans that miss the mark. Treating the behaviour without understanding its function (e.g. assuming rigidity is just autism-related when it may stem from OCD) can result in strategies that feel invalidating or even increase distress.
  • ADHD often coexists with OCD and autism, making accurate diagnosis more complex—but also more essential. Overlapping symptoms can cloud clinical clarity unless assessed through a neurodivergence-informed lens.
  • Stigma and stereotypes often delay diagnosis, particularly for women or quieter individuals. Misconceptions about what OCD or ADHD “look like” can lead to missed or misdiagnoses, sometimes for decades.

LINKS

TRANSCRIPT

JULIE: I’m Julie Legg, author of The Missing Piece and diagnosed with ADHD at 52. Welcome to ADHDifference. In this episode I chat with Cali Keating. She’s a neurodivergent therapist for neurodivergent clients specializing in ADHD, OCD and autism. Not just singularly, she also works with double and triple diagnoses. Welcome so much Cali to ADHDifference. 

CALI: Hello, thank you so much for having me. 

JULIE: All the way from Barcelona. [That’s right, hola.] Hola indeed. Well, I’ve introduced you, wow we’ve got a lot to cover. I was wondering if we could start off a bit about your own ADHD journey? 

CALI: Yes, you know funnily enough I was diagnosed when I was getting trained to be able to treat ADHD. Yes, so I was completing a 40-hour training and executive skills support for ADHD right after I had helped a loved one get evaluated. We were really confused about what was going on with them, why it was so hard to maintain a job, maintain education. I started to learn more about ADHD and then I thought “Wow this is so interesting. I would love to learn more and maybe help other adults with ADHD.” And I’m imagining perhaps you’ve had some other like therapists or clinical specialist guests who sort of in the work you can see the profile and then it starts to feel way too familiar. So I noticed that these inattentive ADHD symptoms like issues in school, issues with relationships, it just started to sound like me. So looking back you know, some of the obvious signs were there. I really struggled in high school. I struggled in university. I didn’t get into my preferred university on the first try. I always had roommate conflicts because of my executive dysfunction. So I’m thinking like listeners maybe having issues with doing the dishes or issues with their partner handling household things, that was you know definitely me. I was checked out in my classes, checked out at work, teaching myself you know my course material later. So when it came time to get evaluated it was almost like my evaluator sort of said “Wow I can’t believe you all missed this. The ADHD is really present and you clearly have an inattentive type.” So yeah, that was in 2020 and yeah now I’ve been working with adults, yeah. That’s brilliant and I guess since you had been working with ADHD and you had a bit of a background in it already, did it come as any surprise when you got your diagnosis? I think there was almost no surprise. I think even clients who I had been working with would notice things like “Ooops she double booked me,” or “She didn’t respond to my email.” So if it ever became appropriate to disclose to a client “Actually I have you know, since we first met, I’ve been evaluated it turns out I have ADHD too,” then they would sort of look at me, sort of think “Yeah we could all tell.” So kind of a funny incident, yeah. 

JULIE: Well I’m very excited about today’s show because we’re going to be talking about multiple neurodivergent diagnoses. Now is there another term for it, for this multiple diagnosis? 

CALI: Yes, I think what’s popular especially in the US is to say ‘multiple exceptionalities’. There’s also a term floating around for folks with maybe two diagnoses that would be ‘twice exceptional’, yeah. 

JULIE: And this is all neurodivergent related? [Exactly, very specific to neurodivergent diagnosis.] Perfect, perfect. Well I’m so excited as I said because we’re going to be talking about OCD, ADHD and autism together. Now my understanding is that it’s actually quite common for someone with ADHD to have an additional add-on, so it’s no surprise but I don’t know much about OCD, so I’d love to hear from you. You’re an OCD specialist; can you talk to me about OCD and then what you refer to as pure OCD? 

CALI: Definitely, so OCD is an anxiety disorder and it’s rooted in a need for cortisol and dopamine regulation. I’ve seen y’all chat a bit about dopamine in previous episodes. OCD operates via intrusive thoughts and compulsions. So everyone has intrusive thoughts but OCD folks are uniquely sensitive to intrusive thoughts and experience an intolerable disturbance around the intrusive thought. So for example, an intrusive thought that I might be contaminated by something, like contaminated by a household cleaner. Perhaps somebody without OCD might notice like “Oh household cleaner, let me quickly wash my hands,” and then that contamination worry goes away. For OCD, the disturbance will remain until they have been able to neutralize that experience of cortisol. So they’re neutralizing the cortisol by completing a compulsion. “Let me wash my hands four times and wash my hands 10 times,” and then whenever they’ve reached whatever that magical threshold is that they’ve sort of decided, they get a nice wave of dopamine. So we get cortisol from the fear from the intrusive thought and then a big wave of dopamine from completing the compulsion. Wow. And yeah, so in Pure O, which is primarily obsessional OCD, folks are not necessarily showing us the physical compulsions. The compulsions are internal. So rumination, avoidance, reassurance, seeking planning, rehearsing, all of these can be internal obsessions. Are you with me? Are you here? 

JULIE: Yeah absolutely. that’s really interesting because a lot of those things, there’s a bit of an overlap isn’t there with ADHD, with the overthinking, and the rumination, and rehearsing. Or you know, as you said you know, thinking about what you should have said several months ago when you had that conversation with XYZ. So you can have OCD without ADHD, and you can have them both together, very interesting. Tell me about some Pure O issues that people may have around like relationships, for example. 

CALI: Yeah you may have come across relationship OCD. That might have crossed your desk. And folks might experience an intrusive thought regarding their partner. Sort of typically the intrusive thoughts that I see around relationship OCD have to do with the core fear of being unhappy. So a frequent thought might be “What if I’m not as fulfilled by this partner as I could be with someone else?” It could be a triggering event might occur like a conflict. And after the conflict our relationship OCD person might be thinking “Really don’t like the way that was handled. Let me just review to make sure that it was handled poorly or that it was handled perhaps appropriately. Let me start to make my pro and cons list. Maybe I should visualize exactly how I would extricate myself from this relationship.” And someone is spending hours inside their own mind evaluating if this relationship is a thing that they want to do or not. And more often than not that person is staying in the relationship. So the way that I often conceptualize OCD is I sort of anthropomorphize it. So it’s like OCD is this bad guy in your head that knows how to exploit you on the things that you value. So if you value your partner, or if you value relationships in general, then intrusive thoughts around this relationship are going to be especially disturbing. Massive amounts of cortisol are being generated when you think “What if I break up with my partner?” And then you can spend hours on that ‘what if’, doing your rehearsing, picking things apart, looking at exact words. And you’ve lost all this time getting dopamine from each little mental ritual, right. So in a way this is… it’s supposed to be helping you. You’re considering scenarios that are not real but it’s supposed to be helping you regulate your nervous system through brain chemicals, right. So with OCD treatment I’m helping people get away from that system of regulation and regulate in different ways. 

JULIE: How do you regulate in different ways? 

CALI: Exactly, right. So we use recovery language like recovery from substance abuse. We use that language to describe OCD. Because using a substance for example, a stimulant like nicotine cigarettes, that’s a dopamine loop. It’s we experience cortisol. We really want that cigarette. We’re starting to feel stressed without that source of regulation. And then we smoke the cigarette and we feel regulated. Nice hit of dopamine you know. Stimulant, just like a ADHD medication is helping you maintain and produce dopamine, right. So it feels pretty good. But for OCD we’re helping folks basically learn how to live life based on values looking at long-term reward instead of living life in these little minutes of doing rituals and getting short-term reward. So it’s a lot like quitting smoking. Wow, wow. A lot of work to be done there. Well, can you imagine having ADHD, having a dopamine disorder, and then your therapist is saying “I’m sorry, you’re not allowed to do your dopamine activities anymore.” It’s really hard. Very very tricky. 

JULIE: What other common traits might overlap between ADHD and OCD? 

CALI: Yes, so many people actually come into my office thinking they have ADHD but it can turn out to be OCD or there’s sort of a hidden OCD along with the ADHD. So I’ve had clients come in saying “I can’t do my schoolwork.” So that seems pretty straight forward. We you know, I talked earlier, most of my issues with ADHD were around school and that you know, okay what’s going on? Oh I’m procrastinating. I’m avoiding. Great. Let’s do procrastination skills but then it turns out that why they’re not doing their schoolwork is because they’re daydreaming. And I think perhaps you know, at first pass you think “Oh daydreaming, not paying attention. You’re not focusing.” But when I helped this client dig in we found out they were doing mental compulsions. They were replaying conversations. Replaying what the professor said. Replaying how the student next to them looked at them when they sat down. Thinking “I really don’t want to go to class because people will notice me. What if I go to class and I cough? Everyone will look at me. If I do this work wrong my professor will think something about me.” And there’s a ton of anxiety that was informing that procrastination. And she was avoiding so that she didn’t have to do her mental rituals. Because she knows “If I go to class, I turn in my work, my rituals are triggered and then I lose hours daydreaming and I can’t do the rest of my work.” Wow. So it’s it was quite sneaky. And it was really helpful to start to pass out the executive functioning that’s due to avoidance and due to fear, versus the executive functioning issues that are due to you know literally disability. 

JULIE: Because when you think about daydreamy often that’s bounced around a lot with ADHD, daydreamy. But really until you get inside their heads and unpack it as you’ve done to find that a client… it may have been classed as daydreamy but it was way more than that. That’s yeah very, very interesting indeed. 

CALI: Something else that can be sneaky, ADHD, OCD, we’re not entirely sure, are coping skills around memory. So a common OCD compulsion you may have heard about can be checking. Checking the locks. Checking the stove. Checking that the pet is where they’re supposed to be, instead of for example, in the dryer, right. But many ADHDers with OCD might see this checking as “Well I’m going to forget. I’ve left the door unlocked before. I’ve left the stove on before so I need to check.” So what I find is when we’re checking to the point of for example taking photos of the stove is off, or taking photos that the garage door is closed, then we’re sort of entering into that OCD territory of I need to do a certain series of behaviors to get that dopamine relief and then I can move on. So what I’m helping folks do is notice have you developed OCD compulsions that are actually your primary format for managing your ADHD? And if that’s the case then I want to help them get into OCD recovery, let go of all the ways their OCD might actually be helping them, that’s helping them not leave the door unlocked, right. And then we are transitioning over into common sense, gentle self-management for ADHD. So we’re coming up with systems that will work most of the time that don’t require rigid adherence to help them essentially make sure that the door is locked, right. So I love to work with the multiple exceptionalities because sometimes OCD is the problem and the solution. So folks can feel really hesitant about letting that go. But if we can embrace a new solution that feels much more relaxed, much more intuitive, then you can spend far less time doing your systems to make sure your home is safe and spend more time on things that you value. 

JULIE: How do you know what’s ADHD and what’s OCD?  And I know you’ve said it’s the excessive amount for example taking photos that you’ve turned the oven off. Is there a bit of a slippery line as to which is which? 

CALI: Definitely. So I will often ask folks a few assessment questions and, depending on the answer, we know it’s OCD. So for example I’ll say “What if I told you that you weren’t allowed to do that, you know? I’m the big mean therapist who you paid to tell you not to do things. So I’m telling you you’re not allowed to check the lock more than once. How would that be?” And if they say “Oh no, that would be horrible. I’m already feeling anxious and this is just a hypothetical question.” Then we’re starting to see okay, look at that. That’s a way to trigger your cortisol so that you’ll go after the dopamine and make yourself feel much better, regulate your nervous system by practicing OCD. If it’s something along the lines of “What if I told you you weren’t allowed to check the lock?” And I go “Well honestly not sure if I would have remembered to check the lock. I only check you know, every other time.” or I say “Well I guess that would be okay. You know, my partner is home for part of the day so if there’s any uncertainty about the door being unlocked I think I could handle that.” Then we’re looking more at ADHD simply memory issues, trying to do the best practice, versus OCD. The key thing here is OCD does not tolerate uncertainty. So the point of a compulsion is to eliminate uncertainty that the door might not be locked. We could also eliminate the uncertainty that someone is mad at you. Eliminate the uncertainty that your deadline for the paper is Friday versus Saturday, right. So if it’s ADHD we’re seeing more “I’m just trying to constantly chase the best practice to manage my life and I get it sometimes but I don’t get it all the time,” and OCD is very rigid. “If you took away my ability to become certain I would be very upset.” Does that feel pretty clear? 

JULIE: That’s great. Excellent. Thank you. So that’s ADHD and OCD. We’ve also got autism thrown in there as well and I know that autism and ADHD, some of those common traits almost are the opposite in many respects. And then you’ve got OCD thrown in there as well. What does it feel like for some of your clients to have all three? 

CALI: So this is actually a big part of my client population and it is a delight to work with these folks. But typically what I’m noticing, and what they’re telling me is, autism often stands out the most. That might have been the first diagnosis if they have multiple exceptionalities, typically diagnosed as a young person or perhaps a young adult. And what we’re seeing in this presentation is it’s social issues, peer issues, communication differences, special interests. This is standing out to teachers, parents, providers, folks who might assist this person in getting their diagnosis, right. But then what’s underneath that, what might not be as obvious, is issues with school work, right. Focus, impulse control, procrastination… if this kiddo in the classroom is already sort of prefers their own company, or prefers to be focusing on their special interest instead of their schoolwork, a teacher might miss the ADHD element there and just sort of be seeing this louder presentation of autism. And then what we find when this person is an adult is the OCD can hide behind the autism traits because there can be rigidity in routines as part of how an autistic person navigates the world. And this can mask the rigid compulsions and OCD. 

JULIE: How would you typically deal with a client if they came in for help? 

CALI: Right, well I love to help folks with this profile because I find there’s a lot of detective work to do and often OCD is the root issue bringing people to therapy even if they haven’t determined that yet. Typically what I’m seeing is there are intrusive fears, very very strong rigid avoidance, or social withdrawal that are causing this individual to not have the social circles that they wish they had or not experience the companionship that they would like. Maybe they’re not completing education or they’re not pushing themselves professionally in a way that they would prefer. They’re encountering this strong sort of internal “No I can’t do that. No I can’t date. No I can’t make friends.” And then when we sort of find out what’s underneath that, underneath that no can be a massive amount of fear. And the avoidance can sort of be part of the compulsion. “I learned a long time ago that if I try to date then I will spiral on that. I will you know, sort of I will inappropriately reach out to that person quite a bit to seek reassurance or I will inappropriately not show enough attention. I will think about it way too much so I avoid dating.” And then we discover that they’re avoiding dating to not trigger their relationship OCD. So when folks come in they’re often telling me “I have multiple exceptionalities. I have no idea how to be an adult. I feel so lost and lonely.” And then if we can treat the OCD then after that we’re just learning how to live well with ADHD and autism. So something I was hoping to mention today is that for me, ADHD and autism aren’t problems to solve but OCD is. So OCD is an anxiety disorder and certain medications can assist with OCD. The type of treatment that I’m trained in heavily assists with OCD with excellent rates of recovery. So somebody can enter treatment for OCD, leave treatment completely in OCD recovery, which often looks like occasional intrusive thoughts that have very low levels of disturbance. And if the individual is thinking “Oh it would be really nice to do my compulsion right now to handle that disturbance,” they know exactly what to do to handle that impulse and they go along their merry way, right. So after OCD treatment somebody can essentially no longer have OCD. The need to avoid, the fear, the need to do compulsion, is gone. They have all the skills they need so that if those impulses come up they don’t have to act on the impulse. 

JULIE: So it’s not a lifetime of medication to treat? 

CALI: No. Many people especially with severe cases medication can be a great option but actually the technique that I use exposure response prevention or ERP, some of the ERP purists are anti-medication which is kind of a controversial take. But they say that if you get off all of your medication and you learn the skills, then you know exactly how to handle your fears for the rest of your life. OCD can be like having 37 phobias at once. And you could take sort of your calming medication, like a benzodiazepine or something every time you have a phobia, or you could go in there, work on the cause of the fear, expose yourself to the fear, get comfortable with the fear, and have skills to handle it, right. To be clear this is sort of very ERP of me to view OCD as something you can recover from, that you can you know for many people get off of your medication, handle your OCD with skills and enter complete OCD recovery. Not qualify for the OCD diagnosis anymore. When I’m helping my folks with multiple exceptionalities, sometimes my agenda is to get rid of one of those exceptionalities which is a take that not everyone agrees with but my clients are finding a lot of success there. 

JULIE: Well that’s amazing. Well any help to dismiss something that can cause havoc in your life I think is brilliant. And if OCD is one of those things that can be dismissed over time with treatment, I think it’s brilliant. I’d like you to share with me if possible, about some common misunderstandings about people who have multiple neurodivergent diagnoses or your multiple exceptionalities. Are there common misunderstandings about these folk? 

CALI: Yes, and I really like this conversation because a lot is coming up especially in the US right now around neurodivergence and the fear of over-diagnosing, right. So many clients when they come into my office they’ll say “You know I came to you because you work with multiple diagnoses but a part of me thinks there’s no way I can have all three.” I hear that all the time, “There’s no way I can have all three,” right. But I’ve noticed there’s this fear of over-diagnosis especially among millennials and Gen X who were here for the sort of late 1990s panic around medicating ADHD especially in young black boys, right. There was a real concern based on real data that we were over-diagnosing people of colour, young boys, saying that normal behaviors were pathologized.  But now we have a lot more information about how autism shows up in women, how autism shows up in adults. For me I see diagnosis as a tool. It helps guide self-care and access to resources. Avoiding the label can keep people from connecting with the communities and insights that could really help them so I don’t have a lot of fear around over-diagnosis. I often help my clients with “Well what if we experiment with maybe you do have all three? What might be scary about you having all three? What might help you about having all three?  How important is it to you to be able to fully understand and commit to I have all three, or I don’t? Perhaps we can use this as a guide to see if we can help you feel better?” And usually that experimentation lens can sort of help folks who might want to dive into the philosophy, the fear, the “Maybe I should get evaluated again. Maybe I should talk to another specialist.” And my folks are so welcome to do that but sometimes that can be an avoidant behavior in itself. It’… “I’ve already sort of gotten my diagnosis. I’ve already started my treatment plan but I fear that there’s no way anyone could be this strange so let me go dig around in the intellectualizing and the diagnostic tools over here instead of digging into the problems that I’m hoping to solve.” 

JULIE: I’d love you to talk to me about the term or the phrase ‘internalized ableism’ and how that might show up in someone’s daily life? 

CALI: Definitely. So I I’m usually looking for a phrase along the lines of “I should be able to do this easily,” right. That seems to be part of the self-talk for many of my clients that they’re comparing their ability level to that of their peers and someone in their family and they’re thinking “I should be able to handle this on my own and why can’t I?” Right? So I’m finding that internalized ableism can be very sneaky that sort of looks like negative self-talk. Perhaps underneath the negative self-talk is a wish. “I wish that I didn’t have to push myself so hard. I wish things came naturally to me. I wish I could spend time on the things I enjoy instead of struggling to complete things that I don’t enjoy.” But there can also be a fear, “I’m worried. I’m worried I will never be able to XYZ.” So what I’m helping folks with quite a bit is what if we do some acceptance around common sense, obvious limit. If it is really hard for you to go to like three social events in a day and you’re thinking to yourself “I should be able to. I see my peers handling three social events in a day. There’s no reason why I should be having a meltdown in my closet right now,” which many of my people have done, right. But if we can accept that that might be a bit too much stimulation for you, that might be a bit too much pressure for you, what if we looked at some common-sense boundaries where you can still spend time on things that you enjoy, prioritize your values then have a lot of time to recover? So for my people who are multiply exceptional sometimes a common-sense boundary is to have limits on the amount of activities they do in a day not just social, but perhaps like “I go to work. I go to school. One activity and then I do something extracurricular. Perhaps extracurricular is cleaning my whole apartment. Perhaps extracurricular is playing with my dog outside for an hour. Perhaps it’s calling my mom,” right, but sort of two activities a day. And somebody who’s multiple exceptional might think “Two activities? That is so limiting. How am I supposed to? How can I complete my, you know, sort of these worries.” But I’m helping folks with prioritizing. If we can prioritize what’s really important to you, you will feel effective in completing what’s important to you. We have to let go of what’s not important, what’s not necessary, what you might be pushing yourself to do past your own limits, and then when you’re only focusing on what’s important to you, you honestly… my folks will feel ‘less disabled’, quote unquote. They feel “I’m effective at what matters to me and when something crosses my path that’s too challenging that I need help and accommodation with, then I know how to ask for that. Because I know what it feels like when it’s too challenging.” Sort of taking away the self-attack of “I should be able to do this easily,” self-attack. “Why am I so bad at this XYZ,” and putting it more into “I can see the systems issues. The system has not been set up to support me and I know what to do.” 

JULIE: You are in Barcelona at the moment but actually you are from Texas, so there’s been some traveling. Yeah. Would you like to share your story with that regard? 

CALI: Certainly. Yeah we spoke a bit off mic about burnout with moving to a new country. Yes.  So yes, a little over a year ago I moved from the US to Barcelona, Spain. And you know, in my arrogance of being a licensed professional I thought I know exactly how to help myself. I’ll not let internalized ableism get me. I will be watching for appropriate limits and you know, this move should be easy, which was a massive over-estimate of what my nervous system can handle. But I noticed that it took me about 8 months to really adjust and recover from sort of the burnout that came with adjusting. And I was able to identify that my skills were… just had gone out the window. They were de-prioritized underneath the disruption of new routines, mastering a language. I already spoke quite a bit of Spanish but it is different trying to achieve fluency and get around and handle emergencies, figuring out healthcare. US has a very strange health care system that’s different from everywhere else in the world and I was not ready to get on board with Spanish healthcare. And then also figuring out cultural norms and managing sort of little micro instances of feeling rejected, or overwhelmed, or I’m not sure how that came across. It was quite emotional. So I noticed that my skills that I work on with my clients, I was having trouble prioritizing those. So a skill I thought I would bring to kind of describe my experience is ABC PLEASE from dialectical behavioral therapy. And this acronym stands for Accumulate positive experiences, Build mastery and Cope ahead. So that’s the ABC. So to be able to try to have a nice time, have many experiences that bring you dopamine, work on building mastery in a skill, and then know yourself so well that if a trigger might be coming down the pipeline, you can think to yourself “Here’s how I’m going to handle it. Here’s what skills I will use. Here’s who will support me.” But when I was experiencing surprises and changes every day, I was having a hard time accumulating those positive experiences, working on building mastery towards something or being able to take care of myself ahead of time. And then the very basic skills of the PLEASE: treat Physical iLlness, which I think is so funny to shove that into an acronym, to have balanced Eating, Avoid mood altering substances, balanced Sleep and Exercise. I struggled quite a bit with the health care system. In the US I had established a relationship with a psychiatrist and I had automatic appointments on the calendar. She would say “Okay, should we meet in 30 days?” I’d say “Sure.” Be on the calendar. They’d send me a text 2 days in advance. They’d call me 24 hours in advance to make sure I show up to the appointment. I could attend online and then she would send my prescription to the pharmacy. So even if I didn’t pick it up for a week, it would be there. And then in Spain, on my sort of foreigner health insurance plan, all of that responsibility was back in my hands to make sure I was going to my appointments regularly enough, to make it to the office, and make it on time. Because those appointments are what like 7 to 15 minutes long and it required a lot of self-management, and a lot of sort of alertness and prioritization of getting to my doctor’s appointment that I wasn’t prepared to have to make that a priority. So, for the first 3 or 4 months, my medication was incredibly inconsistent and I really felt that. I was having a hard time sort of like meal prepping, you know taking great care of my dog, prioritizing like exercise. It had been a while since I had been unmedicated and I didn’t realize how much of a huge help that is to me. And then something I’m not sure how it is in New Zealand but my… the difference from, the difference from moving to the US to Spain.. the biggest difference I noticed was sort of daylight hours, that the sun will go down sort of at 11:00 in the summer here. So I have a lot of daylight which is really nice for my overall mood but not great for my overall sleep. And my sleep schedule was really strange. So I’m not getting my… treating my physical illness, I’m not getting my sleep, not getting my exercise because my medication is what helps me remember to exercise. And then my eating was sort of all over the place because as I’m sure you’ve heard, in Spain people eat dinner at 10:00 in the evening. So my… I could not figure out when to have meals. I was working, I work US hours so I’m kind of working right up until dinner time at until 10:00 p.m, eating lunch at 3 you know, just very strange compared to my normal routine. So I noticed this in myself that I need to sort of take a break. Maybe take a break from the things I have prioritized like forming community and helping myself not feel sort of lonely or isolated, and I needed to come back to when my skills are in order it will be easier for me to be present with community. It will be easier for me to balance making new friends if I can have sort of my foundation. And it didn’t take as long as I thought. So the fear that was keeping me from attending to my ADHD was “Oh no I’ll feel lonely,” and then when I could be with that fear for a couple of weeks and say “Oh well, I’ve been able to have lunch with one person and I’m still you know, I’m here with my husband. I’m spending plenty of time with my husband. Not as lonely as I feared I would be.” And then that self-care was very helpful in me investing in recovering from burnout. And just taking things slower, not over-scheduling so much. So it took me yeah, about eight months to fully stabilize using my own training. But I think it was such a helpful experience as far as my work because now I feel so aware of when ADHDers experience transition of any kind, even if it’s like same country but moving cities, that transition can make us super vulnerable to burnout. So I am feeling better today. You’re catching me you know, at the end of my journey. But in a way I’m pleased to have experienced it for myself so I can really feel that empathy for my clients. 

JULIE: Well I’m so delighted and thank you so much for sharing such a personal journey there. I think just being so raw and honest about it will really help some listeners too who are… maybe have experienced it and thought that perhaps they were battling it alone, or about to perhaps move overseas, and some prep that perhaps they can work on or anticipate. Question too Cali with regards to medication in New Zealand. If you move from overseas to New Zealand, the diagnosis means nothing and you have to be reassessed in order to access medication. Is it the same for you with your US to Spain transition? 

CALI: No, we were very fortunate and this was the small amount of prep work I did do covered to make sure that my assessment would carry over. But I’m thinking I have clients who move to different parts of the world all the time and sometimes doing that prep work is… didn’t make it on the list. They have other things to prioritize, so I’m thinking wow that would be so challenging to arrive and realize I can’t get my medication prescribed until I can see a new provider. So but no, I was able to basically show my treatment plan from the US and luckily I was connected with somebody who is somewhat ADHD knowledgeable. And that’s I think a challenge I’ve noticed is I’m sort of talking my doctors through “Well here’s what I think about my treatment plan and how do you feel?” and I feel like I’m more consulting my doctors and showing up as a consultant to them because I’m trained. And I’ve heard from folks in my peer group that they’re sort of having trouble getting evaluated, diagnosed, you know. People are saying “Let me prescribe you an anxiety medication like Xanax,” instead of an ADHD medication because that provider isn’t very ADHD knowledgeable and they feel that what the person is experiencing is all anxiety. So I do, I feel fortunate that my providers have been open to hearing from me and reading my previous treatment plans but it has been a work of self-advocacy to make sure I can still access care. 

JULIE: Wow. And you said you were working US hours. Are the majority of your clients back in the US or do you provide international therapy? 

CALI: I hope one day to provide international therapy but for now my clients are in the US and that’s sort of a function of my visa. I was able to move to Europe on a digital nomad visa which means that I need to be working in the US and not taking work from a local. And I you know, I respect that. I think that’s a great setup but it does mean that I’m working at 2:00 in the afternoon until 10:00 p.m. But Julie, I wonder if you can relate to this? I am a bit of a night owl and many ADHDers are because we have that delayed circadian rhythm. So once I figured out what time to wake up and what time to eat, the schedule has actually been pretty good. I’m speaking to clients when my medication has kicked in and I’ve had plenty of caffeine. I’m really alert so it could be much worse. 

JULIE: Oh well done. Yes, it’s all about getting yourself all prepped and ready for the day regardless of what time that starts. I had one more question for you Cali and that was with regards to your psychotherapy. You also provide therapy for therapists. Would you be able to share some more about that? 

CALI: Yes, so again this came from my professional journey and my personal journey, I really value as a provider myself, I need to be in therapy to help sort of maintain my mental health and be able to show up with presence for my clients. So when I was seeking therapy after my ADHD diagnosis I noticed sort of a gap in the market that therapists who see therapists are typically more advanced in their career. So many of them have maybe missed the wave of neurodivergent education and some of them you know, are not super active on social media so they might not even be seeing neurodivergent information that’s present in pop culture. So I had to do a fair amount of educating my own provider on “Here’s how to best take care of me and how to help me. And how I might be behaving in a certain way that to you looks like therapeutic resistance, but to me I just completely lost my train of thought and I’m trying to remember what was important about what I was saying.” So I have been focusing on being that provider for other providers. I do have 11 years of mental health experience. I supervise new clinicians and I work with about half my caseload I would say is therapists now which is such an honor. It is really an honor to be a therapist’s therapist and to help them hold space for many people and participate in in healing, you know. But yeah, it was a niche that became important to me because I noticed that with years of experience that doesn’t always mean expertise and sort of the latest research. So yeah I know I really I was excited to assist on this podcast because I noticed that that’s something that y’all really value is kind of being on the cutting edge and staying on top of these topics that are coming out. So I’m hopeful that this conversation will be illuminating for folks. 

JULIE: Absolutely and on that note Cali, I just want to say thank you so much for joining me today. Really learned a lot. Very interesting about our multiple exceptionalities, and OCD and, Pure O, and goodness me. You’ve been really upfront and honest about your journey. And thank you so much. I really appreciate that and I certainly know that our listeners will too. I will have your website link in the show notes for people to see more of you and to check you out. [Thank you so much. It’s been great.] Thank you for your time.

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