ADHD: Why Both Medication and Counseling Matter

When helping our patients who are struggling with ADHD, these are my thoughts around stimulant medications and counseling.

Stimulant medications help patients “zoom into” their thoughts and feelings. This helps them take consistent action that leads to real impact in their lives.

But action alone isn’t enough.

Counseling supports the other side of the process — helping patients “zoom out,” just enough, to get clarity. It can involve defusion, mindfulness and metacognition. It gives people space to understand what really matters to them, what they can control, and what’s workable in their unique context.

It’s not about choosing one or the other. It’s about combining both — in the right balance — depending on the person’s needs and situation.

Because:

 
1. Clarity without action is a problem. You may know what needs to change, but you can’t follow through.
2. Action without clarity is also a problem. You may be doing a lot, but going in the wrong direction or burning out.

A metaphor I often use is this:

Medication gives you the fuel to go somewhere. Counseling helps you figure out where you want to go — or where you need to go.

So in managing ADHD, both medication and counseling are important tools. One sharpens your focus. The other helps you aim that focus at what truly matters.

The best results come when patients are supported to both think clearly and take meaningful action. That’s when things really start to change meaningfully and sustainably.

Feeling Like a Fish Out of Water? 3 Domains to Understand Neurodivergence and Thrive

Understanding Neurodivergence: A “Fish Out of Water” in School and Family Systems

When I screen for neurodivergence—whether it’s ADHD, ASD, or related conditions—I often frame it as a mismatch between an individual and the systems they’re navigating, like school or family, especially in their younger years. It’s a classic “fish out of water” or a “Mac in a Microsoft world” scenario: the environment isn’t wrong, and neither is the individual—it’s the lack of alignment that creates challenges.

I break this mismatch down into three key domains of maladaptation. When someone shows extreme traits in these areas, it can signal neurodivergence, often accompanied by secondary issues like anxiety. Let’s explore these domains and what they mean for understanding and supporting neurodivergent individuals.

Domain 1: Thinking-Biased vs. Feeling-Biased

The first domain looks at how someone processes the world—are they more “thinking-biased” or “feeling-biased”? A thinking-biased individual leans heavily on objective, logical variables, while a feeling-biased person prioritizes emotional, values or relational cues.

If someone’s balance is fairly even—say, 50:50, 40:60, or even 30:70—they’re likely to adapt well to most environments. But when the split becomes extreme, like 90:10 in either direction, adjustment issues can arise. For example, a highly thinking-biased child might struggle to connect emotionally in a family or school setting that values social harmony over logic. This tension can lead to feelings of isolation, frustration, or being misunderstood—a hallmark of the “fish out of water” experience.

Domain 2: Tactical, Operational, or Strategic Orientation

The second domain focuses on how someone approaches tasks and goals: are they tactical, operational, or strategic? In early childhood, schools and parents often emphasize operational skills—getting everyday tasks done, like completing homework or following routines. This operational focus aligns with societal expectations for young kids.

But if a child is wired to be more tactical (focused on immediate, practical actions) or strategic (big-picture, long-term thinking), they might struggle with the operational demands of school and family life. For instance, a strategic thinker might excel at envisioning creative projects but flounder when it comes to the daily grind of assignments. These blind spots can create tension, leading to feelings of inadequacy or conflict with authority figures who prioritize “getting things done.”

Domain 3: Inner-Compass vs. Outer-Compass Orientation

The third domain examines whether someone is guided by an inner compass or an outer compass. An outer-compass orientation means prioritizing what works for others—pleasing teachers, parents, or peers. An inner-compass orientation, on the other hand, is about staying true to one’s own values and thinking, even if it clashes with external expectations.

In early years, schools and families tend to reward outer-compass behavior: following rules, meeting expectations, and fitting in. A child with a strong inner compass—who insists on doing things their own way—might struggle to adapt, leading to friction. They may feel like they’re constantly swimming against the current, unable to meet the external demands placed on them.

When Extremes Collide: The Neurodivergence Connection

When someone is extreme in all three domains—highly thinking-biased, tactically/strategically oriented, and inner-compass driven—the mismatch with traditional systems can be profound. This is where adjustment challenges peak, often manifesting as anxiety, which only complicates the picture further. The “fish out of water” metaphor becomes painfully real: they’re not thriving, but it’s not their fault, nor is it the fault of the environment—it’s the mismatch that’s the issue.

Based on my observations:

• Extreme in all three domains: I’d be highly suspicious of ADHD or ASD, with secondary anxiety due to the intense adjustment struggles.

• Extreme in Domains 1 and 3 (thinking-biased and inner-compass): This often points toward ASD, where logical processing and self-directed behavior dominate, sometimes at the expense of social connection.

• Extreme in Domains 2 and 3 (strategic/tactical and inner-compass), with clear maladaptations: This leans more toward ADHD, with nuances depending on the subtype (e.g., inattentive, hyperactive-impulsive, or combined).

The “Fish Out of Water” Struggle: A Path Forward

For neurodivergent individuals, this mismatch can feel like a constant battle. But understanding the root cause is the first step toward empowerment. It’s not about “fixing” the person or the environment—it’s about finding or creating the right fit.

Here’s the strategy I recommend:

1. Understanding: Recognize how these domains play out in your (or your child’s) life. Awareness is key for both acceptance and to navigating challenges.

2. Self-Acceptance: Embrace your unique wiring.

3. Maintaining Self-Worth: Don’t let societal expectations erode your sense of value. You’re not failing; you’re just in an environment that doesn’t suit your strengths.

4. Seek or Create the Right Environment: Look for spaces—whether at school, work, or in your community—that align with your natural tendencies. This might mean finding supportive social circles, or exploring new settings that feel more congruent and more like “home.”

A Final Thought:

The “fish out of water” experience isn’t a flaw—it’s a signal. By understanding these three domains, we can better support neurodivergent individuals, helping them find environments where they can thrive. Whether it’s advocating for more flexible school systems, fostering self-acceptance, or seeking out spaces that celebrate their unique strengths, the goal is to bridge the gap between the fish and the water. Because when the environment fits, that fish can swim and thrive!

Are You a Fish Out of Water

Feeling Anxious? You might just be a “Fish Out of Water”.  

When we talk about anxiety, it’s easy to focus only on the symptoms—feeling tense, racing thoughts, trouble sleeping, or even physical signs like a racing heart. But there’s a deeper question that can often provide clarity and help us move forward:

Is this anxiety primary, or is it secondary?

In other words—are you living, working, or studying in an environment that doesn’t suit your natural personality or way of thinking/cognition? 

Sometimes, anxiety isn’t the core issue—it’s a signal. A red flag telling you that something about your surroundings or daily routine just doesn’t “fit” with who you are.  Maybe your personality thrives on calm and connection, but you’re stuck in a high-pressure, competitive environment. Or perhaps you’re someone who values structure and detail, but your job requires constant flexibility and chaos. 

This kind of mismatch between who you are and the world around you can cause a chronic, unhealthy level of stress.

When we explore anxiety through this lens, it becomes less about “what’s wrong with me?” or about “what’s wrong around me?” but more about where is the mismatch.  This shift in perspective can be empowering. It can help you:

1. Understand your stress from a new angle. 
2. Make clearer decisions about your environment and lifestyle. 
3. Create or seek out spaces that better support your natural strengths and values. 

Over time, finding or creating a better-fitting context—whether it’s a change in the type of work, relationships, or daily rhythm—can dramatically reduce anxiety and improve overall well-being.

So if you’re feeling anxious, it might be worth asking: Am I just a fish out of water? 

And if the answer is yes, it’s not a flaw—it’s a sign. A sign that it’s time to explore new waters where you can thrive.

Moving towards our values and making it workable rather than running away from it

What we value the most is often what will give us the most pain. If we don’t value it, we wouldn’t care too much about it would we?

Values and pain are often on opposite sides of the same coin.

In counseling work, one of the most common things we see in patients is “experiential avoidance”.

Avoidance of rejection
Avoidance of intimacy
Avoidance of failures
Avoidance of conflict
Avoidance of disappointments
Avoidance of the pursuit our dreams
Avoidance of the “unknown”
Avoidance of “the difficult path”

The mistake that many of us may do is to run away from our uncomfortable and painful feelings, and with such actions, we may unknowingly move away from our values and the life that we want to create. Avoidance may reduce our anxiety, but may worsen our low mood as we move away from our values.

If we want to move towards our values and create a life that we want, we may need to “make room” and “create space” for those inevitable uncomfortable feelings.

With ACT Acceptance Commitment Therapy, we try to help people reconcile and work through the above.

Exploring alternative perspectives to common mental health labels

It’s common for stigma and unhelpful judgements to be attached to those with “mental health” issues. 

If one has a body, one will have some kind of physical health issues. Likewise, if one has a mind, then one will also have some kind of mental health issues. None of us are immune to this are we?

I sometimes prefer to use different terms to describe some of our common mental health diagnoses to reduce stigma, judgements, or to offer an alternative description of the problem perhaps.  It can normalize it to some extent. 

Borderline Personality Disorder to “Emotional Personality”

Attention Deficit Disorder to “Curious and Distractible Personality”

Depression/anxiety to “Adjustment issues with stress response”

ODD to “Inner compass personality”

ASD to “Logical or a more emotionally defused personality style”. 

I also find these especially helpful when taking a transdiagnostic approach to treat mental health issues.

Learning to zoom in and out for better emotional regulation and problem solving

Knowing how to “zoom in and out” from thoughts, data, and feelings is super important for emotional regulation and problem solving. 

But like changing gears, we need to know what those gears are, what they are there for, and what it feels like. 

So let’s start with “zooming in”...

“Zooming into” a thought, a piece of data, or feeling is great for judging something as good or bad. We see it in detail. We get super focused on it. Of course in this state, we can lose openness and curiosity. We are more prone to stress in this state with more fight, flight, and OCD features if overly excessive. The main purpose of “zooming in” is judge and take action. 

“Zooming out” on the other hand is full of curiosity and openness. We see everything as “bigger picture”, and can see things that we were not able to see before when we were too “zoomed in”. We can see many possibilities. It’s great for brainstorming. It may be harder to take decisive action in this state. We are happy to observe the world and “go with the flow”. There may be less stress for us, but our inaction and lack of focus may stress out others around us! The main purpose of “zooming out” is to perceive and gather relevant information without judgement. 

So which one do you tend to overdo or underdo? Which one do you struggle with the most?

Better “zooming” skills=better problem solving=better mood regulation=better biopsychosocial health

Difficult confusing problems may need “zooming out” first before “zooming in” in order to seek more clarity, and avoid falling into the trap of “zooming in” too quickly unless it’s an emergency.

Understanding ourselves through our partner

Our partner is often the most useful “mirror” to see and find ourselves. It’s pretty important to know oneself isn’t it?

We don’t want to be “a fish out of water” due to a lack of self awareness and self understanding.  

If our partner is an introvert, it might tell us that we are more of an extrovert. 

A “fixer/doing orientated” partner reflects a “go with the flow” person in us. 

A “follow my feelings” sort of partner reflects a “follow my head” sort of person in us. 

A “zoomed in detailed” partner reflects a “zoom out bigger picture” person in us. 

A realistic, pragmatic partner reflects a dreamy goal orientated person in us. 

A stability focused partner reflects a novelty and newness orientated person in us. 

An inner compass oriented partner reflects an outer compass oriented person in us. 

And more.......

Don’t get too annoyed by your partner’s differences. Make space for it, acknowledge it, and use it to understand oneself is an important pursuit perhaps.