Podcast Summary: Divergent Conversations

Episode 134 (Season 4): Navigating Suicidality and Safety for Neurodivergent Minds

Host: Dr. Megan Anna Neff & Patrick Casale
Release Date: November 28, 2025

Episode Overview

In this deeply vulnerable and affirming episode, Dr. Megan Neff and Patrick Casale, both neurodivergent therapists, candidly discuss the complexities of suicidality—especially as it pertains to neurodivergent people. Drawing from both lived experience and professional expertise, they break down the stigmas, practical realities, and specific safety strategies regarding chronic and acute suicidal ideation. The conversation balances raw personal insight with practical clinical guidance, emphasizing the importance of open dialogue, supportive community, and tailored safety planning for those navigating these intense experiences.

Key Discussion Points & Insights

The Stigma and Taboo of Suicidality

• [03:37] Patrick: Highlights how suicide is considered taboo and feared, both personally and societally. Discusses concerns that open conversation could trigger action, panic, or unwanted interventions, especially for marginalized communities.

  • Quote:

    "If we talk about it openly, then we're going to act on it... There's even the fear of: can I talk about this with friends, or my therapist, without them immediately going into crisis mode...?" (03:37 — Patrick)

• Dr. Neff: Emphasizes that secrecy and shame intensify the danger, and the need to de-shame and externalize these conversations.

  • Quote:

    "When it's just locked inside of us, it can be very scary." (04:43 — Neff)

Lived Experience: Chronic vs. Acute Suicidality

• [05:02] Patrick and Megan discuss "fantasies of disappearing" and chronic suicidal thoughts, which differ from acute suicidality.

  • Patrick: Reflects on having passive ideation since childhood:

    "It was never active suicidal ideation, but more an unknowing acknowledgment of: I am so overwhelmed and impacted that it takes so much to just exist." (05:11)

• Dr. Neff relates, noting that these thoughts ebb and flow, and the importance of supportive friendships where these topics can be discussed openly.

Clinical Training Gaps & The Neurodivergent Risk

• [07:00] Dr. Neff critiques the narrow clinical focus on acute suicidality, noting a lack of guidance for supporting those with chronic experiences.

  • Quote:

    "There's less training around how do you work with a client who's chronically suicidal... And we know from numbers that this is an experience that impacts our community at significantly higher rates." (07:00)

• [08:09] They share sobering statistics, citing a study that estimates 41% of people who died by suicide in one sample were autistic or had autistic traits, many unidentified.

  • Patrick: "41% of the people...who died by suicide in England were autistic or had autistic traits." (08:09)

Harmful Approaches & The Need for Relational Trust

• [09:03] Patrick discusses how clinical policies often default to crisis handoff, which can rupture trust with clients.

  • Quote:

    "It's almost like... as soon as the word 'suicidal' is mentioned, they stopped the assessment, walked the client down to the crisis unit. I would get so angry by that because it ruptured any rapport that was built." (09:48)

• Both stress the importance of allowing space for honest, nuanced discussion about suicidal feelings in therapy and with trusted people.

The Importance of Connection & Reasons to Stay

• [12:17] Megan and Patrick reflect on what anchors them—mentioning children, friends, and community—and how identifying these motivators can be a vital part of safety.
  • Neff: "My kids keep me here... I know I could have some really dark thoughts and days, and I know that I will—that is not a risk for me to act on." (12:38)

Gradient of Suicidal Risk

• [14:42] Neff and Patrick outline the "gradient of risk" for suicidality:

  • Ideation: Thoughts of not existing or hoping not to wake up.
  • Intent & Planning: Active consideration, research, or organization of means.
  • Warning Signs: Euphoria after making a plan, saying goodbye, giving away possessions, rehearsal behaviors.

  "There can often be a spike of almost like euphoria... The person's made that plan because they're in so much pain, now they're anticipating relief." (15:57 — Neff)

Safety Strategies & Interventions

• 15-Minute Rule & Distress Tolerance:
  Suicide risk spikes in brief, impulsive moments. If individuals can weather the storm for 15 minutes (using distraction, connection, comfort measures), the urge often passes. (19:09)

  • Patrick: "Trying to get through that 15-minute urge that comes over very intensely... after 15 minutes... we're kind of back in a place of more rationally minded thinking." (19:09)

• Means Reduction:
  Reduce or lock up access to lethal means (pills, weapons, etc.), create friction/barriers for impulsive action.

  • Dr. Neff: "Even the process of... getting out the box and doing the code gives me two to three minutes more. That's creating friction..." (23:25)

• Safety Plan Components:

  • Identify early warning signs (especially if alexithymic/interoceptive difficulties)

  • List distress tolerance/distraction tools (pets, videos, sensory comforts, DBT techniques like holding ice)

  • Specify supportive people to contact (and how/when)

  • Create accountability measures (e.g., mutual check-ins)

  • Detail aftercare steps for the coming days/weeks (therapy, community engagement, etc.)

  • Record and visibly list “reasons to stay” (photos, hopes, anchors)

  • Build a hope box (physical or digital) of supportive reminders (34:03)

  • Patrick: "I would almost encourage all of you to create a Google Drive folder or some sort of doc... these are all the reasons I'm going to stick around." (33:34)

  • Dr. Neff: "It's called a hope box... scents bring me back viscerally to positive memories... links to things that remind you why you're here." (34:03)

The Power—and Limits—of Community

• [25:25] Marginalized groups, especially trans and BIPOC folks, face increased risk due to hostility and isolation; supportive community is essential.

  • Quote:

    "Having community, having support is unbelievably crucial... building that into your safety plan: who can I connect with, who do I feel confident and safe spending that time with?" (25:25 — Patrick)

• [27:33] Recognizes that some may rely heavily on crisis lines if no personal connections exist.

Curiosity, Compassion, and Small Steps

• [30:42] Urges listeners and therapists to approach suicidality with curiosity: “Why is this here? What needs to shift in my life to make things more tolerable?”

  • Dr. Neff: "Can we be curious about why is this here... what needs to happen in my life to support some shifts that make life a little bit more tolerable to want to be here?" (30:42)

• Small changes matter:
  "These do not have to be massive. I encourage you all to start small actually..." (31:33 — Patrick)

The Truths Depression Hides

• [36:48] Patrick encapsulates a final message of solidarity, acknowledging the way depression can distort reality.
  • Quote:

    "That depressed mind tricks us and lies to us, convinces us of things that are completely irrational, amplifies things we might have already been feeling... you are certainly not alone in them." (37:11 — Patrick)

Notable Quotes & Moments

• “It takes so much to just exist.” (05:13 — Patrick)
• On safety plans:
  "A lot of deaths by suicide happen in an impulsive moment—just 15 minutes... safety plans, like, absolutely save lives." (21:32 — Dr. Neff)
• On connection:
  "The connection piece, because that's often the lifeline and that's often the thing that keeps people alive, is those—when they do reach out to someone." (29:57 — Neff)
• On sharing with community:
  "I hope that most of y'all have one person in your life that you can go to with this. And if you don't, that person becomes the crisis support person on the other end of that phone..." (27:05 — Dr. Neff)

Timestamps for Important Segments

• 03:37 — The stigma and why it's hard to discuss suicidality
• 05:11 — Patrick’s lived experience: “fantasies of disappearing” and chronic ideation
• 08:09 — Key statistics on suicide and autism
• 09:03 — Failures of current crisis response models in therapy
• 12:17 — What keeps Patrick and Megan anchored; the importance of naming reasons to stay
• 14:42 — The gradient of risk (ideation, intent, planning, warning signs)
• 19:09 — 15-minute rule and using DBT/distress tolerance
• 21:32 — The life-saving role of safety plans and means reduction
• 25:21 — Special risks for teens, trans, and BIPOC populations
• 27:33 — Building safety plans for those without personal support systems
• 29:03 — Details of safety plan logistics and accountability
• 30:42 — Cultivating curiosity and compassion regarding suicidality
• 33:34-34:03 — Hope boxes (digital & physical) as tangible safety tools
• 36:48 - 37:11 — Final affirmations: depression’s distortions & you’re not alone

Final Affirmations and Resources

Hosts emphasize:

• The reality that many neurodivergent people experience chronic suicidal ideation is not a moral failing.
• Open, shame-free dialogue anchored in community can literally save lives.
• If you’re struggling, you are not alone—connections and safety resources are available (see show notes and their website for tools and workbooks).

Closing words:

"We want you to stick around. It's important to try as hard as you can to figure out what you can anchor into, even if it's just for today." (37:11 — Patrick)

Resources:

• Safety planning template (linked via show notes and transcript page)
• Crisis lines, warm lines, and support organizations
• Articles, workbooks, and an upcoming email course on autistic burnout and suicidality at neurodivergentinsights.com.
• Resilient Mind Counseling for ND-affirming therapy

Tone:
Raw, vulnerable, affirming, and practical—delivering solidarity, compassion, and actionable advice rooted in lived neurodivergent experience.