Dr. Annie King

Dr. Sloan Bruan Lorenzini

Welcome to the Sloan Continuing Education Interview Series. I'm Dr. Sloan Bruan Lorenzini, and today I'm joined by Dr. Annie King, a clinical psychologist whose work at the intersection of trauma-informed care and neurodivergence has really reshaped how many of us approach treatment planning. Annie, thank you so much for being here.

Dr. Annie King

Thank you, Sarah. I'm glad we're finally doing this. This is a topic I'm deeply passionate about, and I think it's one that doesn't get nearly enough airtime in our continuing education spaces. Clinicians are hungry for practical guidance here, so I'm excited to dig into it.

Dr. Sloan Bruan Lorenzini

Let's start with something foundational. When we talk about trauma presenting differently in neurodivergent clients — autistic individuals, those with ADHD, other profiles — what are the key distinctions you see clinicians miss most often?

Dr. Annie King

The biggest one, honestly, is misattribution. A client comes in with what looks like emotional dysregulation, social withdrawal, maybe heightened startle responses, and the clinician codes it all as trauma sequelae. And some of it may be. But some of those presentations are baseline neurodivergent traits. If you don't parse that carefully, you end up targeting the wrong thing in treatment. You're pathologizing neurology. I always tell my supervisees: before you write a trauma narrative, make sure you actually understand what the client's nervous system was doing before the traumatic event.

Dr. Sloan Bruan Lorenzini

That's such a critical point. And it leads directly into something I wanted to ask about — the limitations of our standard PTSD protocols when applied to this population.

Dr. Annie King

Right. So if you look at the evidence-based treatments we were all trained on — CPT, PE, EMDR — they were validated predominantly with neurotypical samples. That doesn't mean they don't work for neurodivergent clients, but it means we can't assume a clean translation. Take Prolonged Exposure, for example. The entire model rests on habituation through repeated engagement with trauma memories and avoided situations. But for a client with ADHD who has significant working memory challenges, holding a trauma narrative in mind with the sustained attention PE requires can be genuinely inaccessible. It's not avoidance. It's a cognitive bottleneck. And for autistic clients, the imaginal exposure component can be complicated by differences in how memory is encoded — some clients have intensely vivid, almost sensory-replay-level recall, and others have fragmented, more conceptual memories. Neither fits neatly into the standard script.

Dr. Sloan Bruan Lorenzini

So when you're working with executive function challenges specifically — you've written quite a bit about adapting Cognitive Processing Therapy. Walk us through what that looks like in practice.

Dr. Annie King

Sure. The core of CPT is identifying and challenging stuck points — those maladaptive beliefs that keep the trauma response locked in place. The worksheets are central to the protocol. But the standard worksheets assume a level of abstract reasoning, organization, and cognitive flexibility that many neurodivergent clients find genuinely taxing. So I break them down. I use shorter prompts. I build in more scaffolding. Sometimes we co-create the worksheets in session rather than assigning them as homework. The goal is to preserve the active ingredient — the cognitive restructuring — while adapting the delivery vehicle.

Dr. Sloan Bruan Lorenzini

And what about the sensory dimension? I imagine exposure work gets particularly complicated there.

Dr. Annie King

Enormously. If you have a client with sensory processing differences, you cannot run a standard exposure hierarchy without accounting for that. A fluorescent-lit clinic room might already have their nervous system at a six out of ten before you've even started the session. I've had cases where what looked like trauma-related hyperarousal was actually just sensory overload from the environment. So we have to think about the therapy setting itself as part of the intervention. Lighting, sound, seating, temperature — all of it matters.

Dr. Sloan Bruan Lorenzini

That naturally leads to something you emphasize a lot in your training — building safety through co-regulation before jumping into trauma processing.

Dr. Annie King

Yes, and I really cannot overstate this. There's a tendency in our field — and I understand where it comes from, the research is clear that avoidance maintains PTSD — to want to get to the trauma material quickly. But with neurodivergent clients, if you haven't established genuine felt safety first, you're building on sand. And I don't mean intellectual safety. I mean the client's autonomic nervous system needs to register the therapeutic relationship as safe. For many neurodivergent individuals, that takes longer. They may have a lifetime of experiences where people claimed to be safe but then pathologized their natural way of being. So co-regulation becomes the foundation. That might look like spending more sessions than your protocol manual suggests on building rapport. It might look like adjusting your communication style — being more explicit, less reliant on subtext and nonverbal cues. For some clients, parallel activities during session, like walking or using fidget tools, actually facilitate better processing than face-to-face seated conversation. The window of tolerance work from Dan Siegel's framework becomes absolutely essential here, but you have to recalibrate it. A neurodivergent client's window may look different in width and in what pushes them outside of it.

Dr. Sloan Bruan Lorenzini

I'd love to bring this to life with some clinical examples. Can you share, with appropriate de-identification of course, some cases that illustrate these principles in action?

Dr. Annie King

Absolutely. One case that really shaped my thinking was a young adult client, autistic, with a history of medical trauma from childhood. Previous clinicians had attempted standard PE and the client kept "dropping out" — that was the language in the referral notes. When I did a thorough assessment, what I found was that the imaginal exposure was triggering interoceptive flashbacks — body-level re-experiencing that the client couldn't verbally narrate in real time. So the protocol's demand for a verbal trauma narrative was actually incompatible with how this client's memory system worked. We shifted to a written processing approach, incorporated the client's special interest — which happened to be data visualization — as a framework for mapping their trauma responses. They literally created charts of their physiological states. And it worked. The stuck points shifted. PTSD symptoms dropped into the subclinical range.

Another case involved an ADHD client with complex developmental trauma. The classic CPT homework structure was a disaster — not because of resistance, but because executive function deficits meant worksheets got lost, sessions felt disconnected from week to week, and the client felt increasing shame about "failing" at therapy. We moved to an intensive format — three sessions per week for four weeks instead of the standard once-weekly for twelve. The compressed timeline meant less was lost between sessions. We used voice memos instead of written worksheets. The outcome was strong. But here's what I want clinicians to take away: none of this required abandoning evidence-based practice. It required understanding the mechanism of change well enough to flex the method.

Dr. Sloan Bruan Lorenzini

That's a perfect distillation. Any final thoughts for clinicians who are listening and maybe realizing they need to shift their approach?

Dr. Annie King

I'd say this: meeting clients where they are isn't just a nice sentiment — it's a clinical imperative. If your treatment isn't working, the first question shouldn't be "Is this client resistant?" It should be "Is my method actually accessible to this person's neurology?" That reframe changes everything.

Dr. Sloan Bruan Lorenzini

Beautifully put. Dr. Annie King, thank you so much for sharing your expertise with us today. This has been an incredibly rich conversation.

Dr. Annie King

Thank you, Sarah. I hope it gives clinicians some concrete tools to take back to their practice. This population deserves our best clinical thinking.

Dr. Sloan Bruan Lorenzini

Absolutely. And for our viewers, be sure to check the course materials for supplemental readings and the post-test. Thanks for joining us on the Sloan CE Interview Series.