Patrick Cassell (3:32)

I would assume so, yeah.

Dr. Neff (3:34)

Yeah.

Patrick Cassell (3:37)

So this topic, I think, comes up often and is almost viewed by a lot of people collectively as like a taboo topic. Something we don't openly talk about for a lot of reasons. I think some. There's some perspective. If we talk about it openly, then we're going to act on it. If I talk about it openly with someone I care about, I'm going to scare them into either panic or potential involvement with like a crisis response team or law enforcement, which is obviously quite concerning for those of us in the community who are members of the black, brown, Asian community, members of the trans community, et cetera. And then I think there's even the fear of, can I talk about this with friends openly without them judging me? Can I talk about it with my mental health therapist without them immediately going into crisis response mode, potentially even pursuing involuntary commitment?

Dr. Neff (4:43)

Yeah, yeah, yeah. There's a lot of fear and shame around this conversation. And it's a conversation that when it's just locked inside of us, it can be very scary.

Patrick Cassell (4:59)

Yeah. Yep. So really the segue was that we were talking about ADHD and the myth of laziness and not being motivated and true fashion. We pivoted and diverged into some heavier stuff, really talking about demands of life. And we're kind of joking about if we could trade our neurology and existence. And I think that that sometimes brings this immediate sensation or feeling of relief of man, wouldn't it be nice to go through the world not being so impacted by everything that that comes up? And although we wouldn't trade our neurology for the world, there is realness in that. That statement too, especially when we're struggling. And I know for me, I was kind of talking about disappearing, that fantasy of disappearing. We kind of unpacked that a little bit. And I think I've had that fantasy since I was very young, six, seven years old. I remember just wanting to just not exist. And it was never active suicidal ideation, but it was more so this unknowing acknowledgment of like I am so overwhelmed and impacted all the time that it takes so much to just exist.

Dr. Neff (6:34)

Yeah, yeah.

Patrick Cassell (6:35)

And that has not gotten easier in 39 years of life.

Dr. Neff (6:40)

Yeah, yeah, yeah. I relate to that. I relate to that. And, and I know it's interesting because I know it's something that you and I talk about off air pretty comfortably our own like, because we talk about our mental health struggles with each other.

Patrick Cassell (6:57)

And.

Dr. Neff (7:00)

How this ebbs and flows. And it's also interesting, I don't know what your training was like, but in my training there's a lot of training around how to do a suicide assessment and how to manage like acute suicidality and risk. There's less training around how do you work with a client who's chronically suicidal. And I think in the same ways in culture there's less conversation around how do you manage chronic, whether it's chronic non morbid ideation around just I'm so overwhelmed by my life or whether it is chronic suicidal ideation. How do we manage that? How do we live with that? And I think and, and we know, we know from the numbers that this is an experience that impacts our community at such significantly higher rates. Yeah, especially, especially those who are moving through neuronormative spaces.

Patrick Cassell (8:09)

Yeah, yep. For, for a variety of reasons. And I think you shared a study with me for my TedX that was like 41% of the people in this research study who died by suicide in England were autistic or had autistic traits.

Dr. Neff (8:24)

Yeah, It's a really interesting sober study where what they did is they looked at the people who had died by suicide. I think it was like 9% or less had it in their record. But then what they did is they interviewed family members and looked more closely at the medical record.

Patrick Cassell (8:45)

Right.

Dr. Neff (8:45)

And then based on that it was, they came up with that number that they suspected 41 of the people were autistic. Many didn't know it. And then there's reality. Yeah, yeah, yeah, yeah.

Patrick Cassell (9:03)

So you are asking about my training. It was like laughable, laughably blood bat because again, I don't see that many professors in these grad school programs like that comfortable talking about the topic. It's almost like, okay, client A presents with a B and C, they're actively suicidal. Here's what you do to deescalate to safety plan to crisis plan. Here's how to get client buy in and then how to get like collateral involved as well and supports and to ensure like it was Always like, do you have anything to look forward to if you were here tomorrow? And I was like, this is.

Dr. Neff (9:44)

It's just like motivational interviewing for suicidality.

Patrick Cassell (9:48)

Yeah. So if you were here tomorrow, do you have anything to look forward to? Or do you have anything to look forward to in your life or would anyone miss you? And like, questions like that. And you're almost like putting this guilt back on the client in that way. I think so often in mental health spaces, in Western culture especially, we are trained to immediately go into crisis and safety planning when the word suicidal is mentioned. I think it's sometimes a CYA process of like, I just have to get this plan done to cover my ass in case this person actually acts on this. And that's really unfortunate. I worked in a crisis unit that was a walk in 24 hour crisis unit. People could just walk in off the street in distress. And we had a lot of clients who were actively suicidal. But because we were better prepared in that unit than our outpatient counterparts, we were able to talk with these clients openly and allow them to build trust with us to talk about passive or chronic suicidality without that shame or that judgment or that stigma. And in turn, unfortunately, what I saw a lot of the time with our outpatient clinic was that the term or the word suicidal was mentioned and they stopped the clinical assessment in its tracks, walked the client down to the crisis unit and would hand them off to us and say, this person's suicidal. And I would get so angry by that because I just thought you just ruptured any rapport that was built because this client is not going to die by suicide in your office while you're com. While you're completing a comprehensive clinical assessment.

Dr. Neff (11:27)

Yeah. You have to be able to talk about this in therapy. And then especially if it's a chronic experience, the ebbs and flows, you have to be able to talk about it and talk about it deeply, not in a trite way, because. Yeah. Of like, what does keep you here? What. What is the meaning? And also being able to talk about the experience of when life just feels like too much. Yeah. Yeah.

Patrick Cassell (11:58)

And that's why, you know, I value our friendship and a couple of other friends of mine who we can have these conversations pretty, pretty candidly and really transparently. And we always use like the caveat of like, I'm not thinking about doing anything or there's, you know, and I.

Dr. Neff (12:17)

Mean, I think that's part of what keeps our conversations feeling grounded, is when we do talk about it, it is. We also are Always listing the things that keep us here. Right. So like for me. Yeah. And ideation, both kinds have ebb and flowed throughout my life. Obviously when I'm depressed it is much worse.

Patrick Cassell (12:37)

Yeah.

Dr. Neff (12:38)

And I know without a doubt, like my kids keep me here and that's just. It's a non, it's a non negotiable in the sense of I know I could have some really dark thoughts and days and I know that. Yeah, I know that I will. That is not a risk for me to act on.

Patrick Cassell (13:03)

Yeah.

Dr. Neff (13:04)

And being able to talk about the thoughts when they do come with people like you or my therapist who also. Well, it's the balance of like understanding the things that keep me here has been really important.

Patrick Cassell (13:20)

Yeah, same. You know, I have a handful of friends who I can talk pretty openly about, yourself included and another good friend that lives here in town. And we kind of have this exchange in that way of like this is where I'm at, you know, this week or this day. And this is what I've been thinking about. And I think we need to be able to openly talk about this stuff without that fear of like someone's immediately going to spring into action against my will or in my. Within my, you know, consent. Just being able to openly discuss kind of for me allows me to just normalize the experience of like I've been flow through this, I've done. I've been flowed through this my entire life dating back to childhood. I've never been to the stage of like intent. I've never moved into the stage of action. It's just always been ideation. And I acknowledge that as long as it can stay ideation and I can openly talk about it in a safe space with people that I trust, then it, then those. The ideation just stays what it is.

Dr. Neff (14:33)

Yeah.

Patrick Cassell (14:34)

And it doesn't feel as overwhelming to me because I just acknowledge it as like almost a baseline.

Dr. Neff (14:42)

Do you think it would be helpful to talk through the gradient of risk? Do you think that'd be helpful information for folks? Yeah, yeah, yeah. So there is like a gradient of risk which can kind of be. I think it's helpful because it's kind of a thermometer of like, okay, this, this is reaching. I mean it's all of it scary. But where it's like, this is a point where like definitely seeking help and definitely talking to someone is like really important. And so like you just mentioned a few, you mentioned ideation and that, that can be that non morbid, like hope I don't wake up.

Patrick Cassell (15:22)

Yeah.

Dr. Neff (15:22)

Or it can be. It can have a more suicidal nature. And then there's intent and planning, which is where it's like, actually, this is something I'm moving toward. And I'm like, a person might start researching or thinking through different ways, and then that is a much. Once we get to that place on the gradient, like, a person should definitely be seeking help.

Patrick Cassell (15:56)

Yeah.

Dr. Neff (15:57)

One thing that is common to see is when someone has made the decision. And if it's a plan, there can often be a spike of almost like euphoria or dopamine, partly because often the person's made that plan because they're in so much pain that now they're anticipating, like, relief of that pain. But also it's kind of like a existential BTFI beyond the it. And so it's like there can be kind of a big bump of if someone's been really depressed, like a bump of energy or positivity. And that. That can be like, for the people around that person's life, that can often be kind of a signal of, like, that this person's in a really kind of dangerous spot with it.

Patrick Cassell (16:49)

Another signal or warning sign that someone has moved from ideation to intent and plan to act is saying goodbye to people, giving away possessions, gifting things to people. That can often be an indication that there's more significance here than. Than ideation happening behind the scenes.

Dr. Neff (17:18)

Yeah, yeah, yeah.

Patrick Cassell (17:20)

And.

Dr. Neff (17:24)

Another, I think, red flag to pay attention to is like, rehearsal behavior. If someone does have a plan in a tent that they. It can be common to almost kind of have activities of rehearsing it. And that. That gets really scary for a few reasons. One, Because it's kind of a preparation for. But also, like, the kind of. The neural pathways you're creating is. Especially if this happens after, like, a spiral, an emotional spiral over time, what the body starts learning is like the exit ramp from this pain is either thinking about ideation, planning for it, or rehearsing it. And that's not a neural pathway that we want to be strengthening. And so that is also one of the things we want to be watching out for. But also if we do have a neural pathway of, like, I get really emotionally dysregulated, or I have a sensory meltdown or shutdown, and then I'm. I'm thinking and I'm planning or I'm rehearsing, like, that's a time where we really want to try to intervene with that process and create an alternative. Like, that's where distraction techniques, distress tolerance, where you're Creating a different neural pathway after you have an emotional or sensory meltdown. Especially because one thing we know is that a lot of deaths by suicide happen in an impulsive moment where if that person could have just made it through that 15 minutes. Yeah, they could still be here.

Patrick Cassell (19:09)

Hey everyone, it's Patrick. One half of Divergent Conversations. Some of you may know that I own a group therapy practice in North Carolina, Resilient Mind Counseling. We specialize in supporting the neurodivergent LGBTQIA and black, brown and Asian communities online and across North Carolina. We also have limited in person openings at our offices in Asheville and Cary. We really love working with clients who are coming to terms with both autism and ADHD discoveries later in life or questioning, as well as the intersections of race, gender identity and orientation. All of our therapists have lived, experience and identify as adhd, autistic or adhd. Our team of affirming therapists offers a safe, anti racist, anti oppressive, inclusive and accessible space where you can show up exactly as you are. No masking, no judgment and no need to make eye contact. Just real connection and healing. We accept most commercial insurances like Blue Cross, Blue Shield, United, Aetna and medcost, as well as self pay options. We currently have openings for new clients and you can visit our website@resilientmindcounseling.com and if you would prefer, you can either text or call to get started to our HIPAA compliant phone line at 828-515-1246. You can also email us at schedulingisiliantmindcounseling.com yeah, it's similar to like a SUDs assessment for substance use. Like subject or subjective units of distress or significant units of distress. God, I can't ever think about the name. Trying to get through that 15 minute urge that comes over very intensely. It's like a wave when it comes crashing in and weathering the storm, so to speak. So having some strategies and supports in place, people you can connect with in contact, if that stuff is coming in intensely like that, usually what we see is after 15 minutes of kind of weathering the storm that kind of dissipates and then we're kind of back in a place of more rationally minded thinking because what we don't want to be doing is acting in that impulsive place. Similarly, again, going back to like addiction. That's why they so often coincide, unfortunately. Addiction and death by suicide. But it is weathering that like 15 minute urge.

Dr. Neff (21:32)

Yeah, yeah, yeah, I'm glad you mentioned that. That. Yeah. So one addiction's also in the mix. The risk goes way up because we're much more impulsive when we're intoxicated. Yeah. And this is where. So I know you and I have both like kind of eye rolled. You know, someone mentioned suicidal ideation and therapy. The therapist pulled out the safety plan. But. And it's when, when it's done that way as a way of like we can't talk about this. It's like. But safety plans, like safety plans, absolutely save lives. And that is why is because most many of the deaths that happen happen in that like intensity of that 15, 20 minutes. And so if, if you can. I think some of the biggest things. I would say the two biggest things. Having a safety plan and, and one that's really accessible and then redu, like reducing means. And so by that it means like reducing access to things that could be used in that 15 minutes period. Because when we're living with chronic suicidality and especially if there's addiction in the mix, especially if you're prone to emotional sensory meltdowns, which many of us are. It's like my present self needs to prepare for my future self, which might not have access to my prefrontal cortex might not have access to kind of. Yeah, yeah, yeah.

Patrick Cassell (23:03)

Well said. And I think that means removing things from the house or locking them up or having a trusted human being in your life take them. That could mean weaponry, that could mean like pills. That could mean anything. Getting them out of easy to access locations, making sure that you do not have them within arm's length.

Dr. Neff (23:25)

Because even like, even having a pill box, like which that's something we have in our house is like a pillbox with a lock and it, it's kept high. And even so for folks, even the process of. If I have to get on a chair to get out the box and to do the code that gives me two to three minutes more. Right. Where I have to think through that, like that's creating friction and it's like I not have to think through it each step of the way.

Patrick Cassell (23:57)

Yeah.

Dr. Neff (23:57)

And. And that's essentially so things like pills. Like a lot of us have pills in our house because we're complex. So that would be an example of like reducing means or adding friction or even. This is really. I know this is obnoxious for us, but it's like when it's. When it's really chronic suicidality of like having shorter prescription. So it's like you're only getting like two weeks at a time versus and again, I know, I know that's not very ADHD friendly, but. Yeah, reducing means is I think one of the most important things that we can do.

Patrick Cassell (24:44)

Yeah. And going back to the pillbox, if you have a lock on it and you are living with someone or you have a friend or whoever's involved in the safety plan and they have your consent to change your combination to that lock.

Dr. Neff (24:56)

Yeah, yeah, yeah. So that's actually what we do is we have like a weekly pill bottle and we do those every week and then everything goes back up. Yeah, yeah, yeah. And if you've got. Oh gosh, this episode is so scary, but it's so like important if you've got teenagers in the home. Like, these are also things like we know suicidality is increasing among teens.

Patrick Cassell (25:21)

We also notice among the trans population right now.

Dr. Neff (25:25)

Trans. Yeah. And the, the bipoc population.

Patrick Cassell (25:28)

Yep. Because of messaging. That's being.

Dr. Neff (25:31)

Yeah, yeah.

Patrick Cassell (25:32)

Broadcast. Because of media. You know, I myself had a gambling addiction for 10 years of my life and impulsivity was through the roof. So I flirted with this more then than I do now. And also just, you know, I think community is so important. I had a friend recently and I know I have her permission to share this, I'm going to be vague about it, but she brought like, hey, I've been recently like having some significant suicidal ideation. No plan, no intent. But she brought it to a team or a group of colleagues and they kind of just sat there like silently like cricket based silence. Like we don't know what to say. And I think that happens a lot, you know, so having community, having support is unbelievably crucial. And that means like building that into your safety plan of who can I connect with, who can I reach out to? Who do I feel confident and safe and secure spending that time with and, and sharing these thoughts with?

Dr. Neff (26:39)

And I think that part's so important of like, who, who can hold this? Because it brings up anxiety for humans. And so, so like understanding who, like, who are the people that I can go to? Because. Because it's worse to open up about it. Like, like what your friend experience and then have that cricket experience.

Patrick Cassell (27:05)

Yep.

Dr. Neff (27:05)

And, and so knowing like, who are the people I can text or call and it might be a crisis line. And if that's like, if, if there, I hope that most of y' all have one person in your life that you can go to with this. And, and if you don't, that person becomes the crisis support person on the other line of that phone and that's why they exist.

Patrick Cassell (27:33)

Absolutely.

Dr. Neff (27:36)

Yeah. Yeah. I wonder if we should almost. We could like walk through the components of a safety plan and actually I've just decided as we're recording this, like I'll make, I'll make a template so that people can have it and it'll. Let's just. I don't know how to link downloads in our show notes, but. Oh, we have transcripts on our website. We'll link it there. Yeah, but yeah, that's like one of the first. Well, I guess part of a safety plan is like knowing what your signs are. And again, this is. This becomes really important when we have alexithymia and interception differences. Because part of alexithymia is we often. Because we're struggling to identify our emotions. It's like we don't. Back to that suds thermometer. We don't necessarily know when we're like, we might be at like a two or a three and then we don't register the emotion till we're at a 10.

Patrick Cassell (28:24)

Right.

Dr. Neff (28:25)

And at that point. So we can have a lot of emotional spikes and at that point emotions become a lot harder to regulate. And so knowing what our tells are that we're getting into a scary spot. That's important for all safety plans. But then especially when you're autistic or adhd.

Patrick Cassell (28:45)

Yeah.

Dr. Neff (28:46)

Those tells might look a little bit different because you might not emotionally be registering it. Maybe it's tracking your thoughts or your behavior, like more withdrawal or more. I would say probably our thoughts. Like that's what I track mostly is my thoughts.

Patrick Cassell (29:03)

Yeah. Yep. So tracking that behavior, big part of a safety plan, having people who you can contact if you need some accountability measures building in. I am going to contact Megan Anna by tomorrow at 9am and I'm going to do it via text. I'm going to do it via phone call. Building in how you're going to reach out to your supports and also building in, do your supports have permission to reach out to you and how often will they be checking on you? Will they be checking on you twice a day? Will it be in person? Will it be over the phone? You know, building in the very specific examples of how you are going to be linked to that community, to that support system, who those people are going to be, what their contact information is. Do they have your consent to come and check on you? Yeah, really important.

Dr. Neff (29:57)

Yeah, yeah. That connection piece. Because that's often the lifeline and that's often the thing that keeps people alive is, is those. When they do reach out to someone.

Patrick Cassell (30:08)

And yeah, and we need almost an aftercare plan as well built in of what am I going to do over the next couple of days, what am I going to do over the next week, what am I going to do over the next month to kind of strengthen this foundation that I'm building in the safety plan? Does it mean I'm going to get back into therapy? Am I going to increase the frequency? Am I going to spend more time at community based events and meetings and groups like really getting very intentional and specific about that when you, when you can think rationally about what those steps are.

Dr. Neff (30:42)

Part of what I hear and I, and I think this becomes really important. Those questions foster curiosity. And this is, again, this is why it's really important that we be able to talk openly about this with our therapists is if we're experiencing this, something in our life is not working. Maybe it means that we are incredibly depressed and maybe there's a medication change that would be helpful. Maybe it's structurally something in your life is not working. But it's. Can we be curious about why is this here and like, like what needs to happen in my life to, to support some shifts that make life a little bit more tolerable to want to be here?

Patrick Cassell (31:33)

Yep. These do not have to be massive. They do not have to be massive shifts. I encourage you all to start small actually. So it's thinking about what are the little things that can, can be changed that I do have control over that I'd like to incorporate more or less of or how can I do more of the thing that I want to do or how can I do less of the thing I don't want to do. Hell, animals are a great support system for those of you who don't have them and enjoy them and can have them. You know, because when we start to think about reasons to stick around, you know, I think that's important if you don't have children, if you, if you aren't partnered or happy in that partnership, like there's got to be something to anchor into.

Dr. Neff (32:19)

And that I guess that gets back to the safety plan is also like, oh, I'm thinking a combination of things kind of comfort and distress tolerance skills of, especially if it's one of those like intense spikes where we're having that kind of 15 minutes of intensity.

Patrick Cassell (32:34)

Yeah.

Dr. Neff (32:34)

Having a list of things that are distracting, which, which could be pets or pet videos or, and things that are, that help us with distress tolerance. So there's a lot of distress tolerance Skills from dbt, things that like change our physiology. So sometimes you know, things like holding an ice cube or there's a lot of things with like water temperature that we can do, but things that kind of help to get us out of that 10 a little bit.

Patrick Cassell (33:03)

Yeah.

Dr. Neff (33:04)

And comfort, like distress tolerance comfort. But then I also heard you list like reasons to stay. So having a section where we list out like these, these are the things that matter to me. These are the reasons I stay. Because again if we're in an intense 15 minutes, we're not going to have access to that. And so being able to physically see that list that, that our past self has reminded us.

Patrick Cassell (33:30)

Yeah.

Dr. Neff (33:30)

Becomes an important part of that component as well.

Patrick Cassell (33:34)

I would almost like encourage all of you to create a Google Drive folder or some sort of doc that has links to videos that, that, that cheer you up or make you laugh or feel connecting or music or photos or future plans or any of those things that you can just access as a one stop shop for a resource that's almost just like these are all the reasons that I'm going to stick around.

Dr. Neff (34:03)

And you're probably familiar with this but there's this idea of building a hope box which is where you put like photos or I actually really like scents because scents bring me back really viscerally to positive memories. Or basically it's a box of the things that are. You might also put some distress tolerance tools in there as well. But it's a box that reminds you what matters to you, reminds you why you're here. And so it's called a hope box. But I do feel like more and more as we move digitally like creating a digital hope box, like as you're describing that I was like, oh, that'd be cool to have like a digital hope box where it's. Yeah. Links to videos that are, are distracting or links to things that remind you why you're here. That, that could also be a really neat. Neat doesn't feel like the right word. That could be a really helpful resource for folks and, and the. We know like we know that that's something that helps again if we're, especially if we're living with chronic suicidality is because a lot of it's again, where when we have access to the part of us that is, is more grounded and knows why we're here. It's like we, we want to be able to send messages to the future self. Whether that's a letter or a hope box that's digital or physical.

Patrick Cassell (35:26)

Absolutely. Yeah. Yep. Yeah. Again Heavy topic, necessary topic. I think we don't talk about this enough. So if you're listening and it resonates for you or for someone you care about, really hope that this, this helps you just, even if it's just for today.

Dr. Neff (36:00)

Where, where did your mind just go? I.

Patrick Cassell (36:04)

Just, you know, I, I, I think this is a topic that's near and dear to my heart for a lot of reasons. So I've never shied away from talking about it. But I also want to, I think we, you know, just treading delicately here and yeah, I just want to just emphasize everything that we've said and just trying to figure out what to anchor into, to stick around one extra day, get through that 15 minute window. When that comes over you, acknowledging that these thoughts are really a part of existence for a lot of people, you're certainly not alone in them and you just want to name that.

Dr. Neff (36:48)

Yeah, yeah, yeah. When we're in this level of like intensity, I just feel like there it's hard, it's hard to hold on to some truths of like the fact, the reality that, yeah, you know, that depressed.

Patrick Cassell (37:11)

Mind tricks us and lies to us, convinces us of things that are completely irrational, amplifies things that we might have already been feeling to some degree. And just to remember that. Yeah, yeah, we will, we will link some resources to this in the show notes for you all and you know, we appreciate you listening to that episode and sticking with us for that. And you know, I don't have a good way to, to end this episode other than to just say that we want you to stick around and it's important to just try as hard as you can to figure out what you can anchor into, even if it's just for today. Yeah, again, sorry y', all, but gotta transition out. So check us out on the platforms and YouTube on Fridays and we'll see you next week.

Dr. Neff (38:06)

If anything in today's conversation stirs something up for you, you're certainly not alone in that experience. And please do reach out for support. Support is one of the things that helps us to be able to stay. We've included warm lines, hotlines and other support resources in the show notes and the Neurodivergent Insights team and I have created a free full length workbook with resources. All of these resources are available on the Divergent Conversations episode page, which is linked to in the show notes. Thank you for joining us for this important conversation. Thanks for. I know that personally after I recorded this conversation, I had some ripple emotions that took me a while to get out of and so I can imagine for many of you listening, you might also have some ripple emotions after dipping into this content. So please do resource yourself. Support yourself. Consider what sensory supports might be helpful for your system. This is an important conversation and it can also stir up a lot for us. So so please, please do take care. Hey, it's Dr. Neff here. This season we are clearly talking about autistic burnout, a topic that neurodivergent Insights has covered extensively. So if you would like more resources to supplement your learning, we've put together a page where we've curated all of our autistic burnout resources freed and paid resources. We have lots of articles on autistic burnout. We have a upcoming free email course. It's going to be released soon. We have workbooks on autistic burnout. So if you'd like to check out our resources again, both free and paid, you can go to neurodivergentinsights.com burnout-resources it's linked below and in the show notes. I hope you don't need these resources, but if you do, they are there for you.