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The Divergent Conversations Podcast is hosted by Patrick Casale and Dr. Megan Anna Neff, two AuDHD mental health professionals and entrepreneurs, as well as features other well-known leaders in the mental health, neurodivergent, and neurodivergent-affirming community. Listeners know, like, and trust the content and professionals on this podcast, so when they hear a recommendation on the podcast, they take action.

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[FLASHBACK] Episode 7: Finding a Neurodivergent Affirmative Therapist

Jan 04, 2024
Divergent Conversations Podcast

Show Notes

Finding a neurodivergent affirmative therapist is important for individuals who are Autistic, have ADHD, or have another diagnosis.

However, it isn't always easy to connect with a therapist who is willing to explore their client's special interests, even though it can help them feel more comfortable and relaxed during therapy sessions.

There are some therapists out there who shy away from or just don't understand neurodivergent minds and thinking, despite what claims may be on their profiles, which can make finding the right therapist a challenge.

But neurodivergent affirmative therapists are out there. You just need to know what to look for.

If you are looking for a neurodivergent affirmative therapist and aren't sure where to start, then this episode is for you.

Top 3 reasons to listen to the entire episode:

  1. Learn how and where to find a neurodivergent affirmative therapist who can support your unique needs.
  2. Identify what to look for and expect in a neurodivergent affirmative therapist and what therapy modalities are generally most helpful for autistic and ADHD individuals.
  3. Identify some common misconceptions about what kind of therapy works best for neurodivergent folks, as well as hear about Megan and Patrick's personal experiences.

Remember, finding a neurodivergent affirmative therapist can be a challenge, but with the right tools and information, it's absolutely achievable. Keep advocating for yourself, and know that healing and overcoming shame and stigma related to seeking therapy is a testament to your strength and resilience.

Additional Resources:

 


Transcript

PATRICK CASALE: Hey everyone, you're listening to another episode of the Divergent Conversations Podcast. I'm one of your cohosts, Patrick Casale, joined today by my other cohost…

MEGAN NEFF: Dr. Neff. 

PATRICK CASALE: And today we're going to talk about finding a neurodivergent affirmative therapist and how complicated that can be, questions to ask, things to avoid, resources, etc. So, a really cold topic segwaying off of our Megan and my conversations around our own diagnosis history, and stories, and some of the personal pathways into kind of finding therapy for ourselves and how challenging that has been. 

And I think it's been a rough road. But I think we both kind of have got that sorted out now. But I think it's taken a long time, and a lot of trial and error, and a lot of misdiagnoses, missed opportunities, and unfortunately, sometimes some trauma involved as well.

MEGAN NEFF: Yeah, that's a good summary of it. I'm curious because I know you really like your current therapist, how did you find her? Were you specifically looking for a neurodivergent affirming therapist or was it coincidental?

PATRICK CASALE: It was coincidental because when I was looking I had not even gotten my results back from the testing that I had done yet. 

MEGAN NEFF: Okay.

PATRICK CASALE: So, I was looking very specifically for someone who could support me with certain things like feeling like I'm never doing enough, I'm being lazy, I'm being unproductive. 

MEGAN NEFF: All these ADHD things. 

PATRICK CASALE: Yeah, all the ADHD things really of like, and I also wanted to finally try hard to absorb and take pride in some of my accomplishment instead of just moving to the next thing. Simultaneously, was doing testing to set… Ooh, words, to figure out if I was autistic, if it was ADHD, if I was missing something, and got my results after I had scheduled an intake with her. So, I was really actually very anxious about that first interaction because I had heard some horror stories from some friends who had recently been diagnosed as autistic. They had told their therapists and their therapists, like, kind of in the middle of conversation were just like, "Yeah, I don't feel competent enough to help you and I'm going to refer you out."

MEGAN NEFF: Yeah, yeah. I see and hear about that a lot. Like, sorry, can't touch that. 

PATRICK CASALE: Yep. 

MEGAN NEFF: Refer you to a specialist. Yeah, totally.

PATRICK CASALE: Yeah. And I think the problem, you know, is who are the specialists?

MEGAN NEFF: Right? 

PATRICK CASALE: And [CROSSTALK 00:02:49].

MEGAN NEFF: They're working with kids.

PATRICK CASALE: Yeah, they're working with kiddos. And a lot of the times they're also practicing from an ABA model. And I think that just like any other marginalized group, when someone says, like, we're anti-racist, or we are pro-BLM, or we are like, supporters of the LGBTQ community, it's very easy to just say that and not have its meaning-

MEGAN NEFF: Oh, my gosh.

PATRICK CASALE: …or the [INDISCERNIBLE 00:03:15], or the ongoing consultation. So, I think it's very easy to get caught in between the like, finding the person who knows a little bit about neurodiversity, but like really isn't a specialist, but like, at least is open to working with people. And I think that's where a lot of people end up because we have so few resources out there, at least, in my opinion, in western North Carolina, for sure.

MEGAN NEFF: Yeah, yeah. And like, I hope this is encouraging, this probably isn't a super popular opinion, but I am less, and part, probably because of my experience with my previous therapist, but I'm less convinced the person has to be a specialist in neurodiversity and way more about their attitude, and their energy, and their ability to be curious, and their ability to be relational, and ability to be interpersonal. 

Like, if you find someone who is curious with you, and will engage in the interpersonal process of like, what's happening here? Can we understand that? Do we have this like psychic strength to tolerate looking at that? Then I think you're in good hands. 

So, for me, often it's less about what trainings have they done? What do they know? And more about who they are as a human and are they open to being curious about this with someone?

PATRICK CASALE: Yeah, I agree 100%. And I think that, you know, for any therapeutic relationship that's really crucial much more so than like trainings, or certifications, or letters behind someone's name.

MEGAN NEFF: Yeah. 

PATRICK CASALE: And, you know, we still see a lot of therapists who say like, I specialize in ASD, or I specialize in [CROSSTALK 00:05:08], or whatever the case may be and you're like, "Well, I'm not going to refer to this person probably, so I'm checking that one off the list."

So, I think you're right, though, I mean, the curiosity piece and the ability to just really be open and to even be learning as they're going. You know, a lot of therapists, well, I think all therapists should be doing continuous lifelong learning, but the ability to do so with a client who they may be unfamiliar with, or they don't have much background in working with, I think that's really important as well. And that goes a long way to kind of build that trust and rapport.

MEGAN NEFF: Yeah, yeah, absolutely, absolutely.

PATRICK CASALE: And, you know, I think the horror stories we hear a lot of like the, "I told my therapist this and they referred me out." And I used to experience that a lot when I only worked with male-identifying clients who were struggling with addiction, a lot of them would come to me and say, like, "I talked about my drug usage or my, you know, lack of sobriety and they stopped to listen."

MEGAN NEFF: Yeah, that's a really common refer out, yep, yep.

PATRICK CASALE: Yep, like middle-of-conversation stuff. Like, someone's saying, like, "Hey, I relapsed and I went back to using amphetamine." And then the therapist saying like, "Whoa, all right, this isn't for me, I'm going to refer you out." But I've always…

MEGAN NEFF: No shaming.

PATRICK CASALE: It is.

MEGAN NEFF: Can you imagine disclosing that and someone be like, "Oh, no, okay, I can't handle you."

PATRICK CASALE: Right and like, what do you expect to be happening in the middle of that therapeutic conversation? Like, you can't wait until the end of the session to have that conversation about referrals?

MEGAN NEFF: 

Right, or even to take an interpersonal approach of like, I'm hearing this and I care deeply about you, and here are some of the things coming up for me around this of this isn't my background, and I'm wondering am I the best person to support you through this? And then, like to process it with the person versus just not, "Sorry, no." And I mean, talk about like an attachment injury. There's just so much about that, that makes me cringe.

PATRICK CASALE: I thought it was mind-boggling. And I thought, you know, this person was just… this was being embellished, then I met the therapist, and they like, confirmed everything, they're like, "Yeah, I said that that's how this went, that's how I referred them to you." And I was like, "What the fuck?" Like, you can't just… I think therapists are so often unable to handle, like, healthy confrontation and feedback process in a relationship. So, we avoid it and then it's like, I'm going to cover my ass, so I think the best scenario is like refer out, refer out, refer out.

MEGAN NEFF: Yeah, there's a lot of cover your ass, and that thing, again, what happens to the person when they feel like a liability? I've just disclosed something really vulnerable and I'm now a liability. 

Like, Martin Buber is a philosopher, I'm a big fan of, and he talks about the I thou, I it encounter of like I thou is seeing the sacredness of the other I it, it's that kind of objectifying. Like, in that moment of I can't handle you, I'm referring you out, like that became an I it moment. And in a relationship where they're supposed to be a lot of I thou encounter, it's so wounding.

PATRICK CASALE: It's really wounding and you know, I think so often, right, if we're talking about people who are ashamed of their diagnosis or their presenting concerns, and they've been stigmatized and discriminated against, and you come into therapy, a place where like, you've finally been able to pick up the phone or email and finally made this appointment, and then that is the response, the odds of you seeking out therapeutic support ever again in your life drastically reduces.

MEGAN NEFF: Yeah, and this is something I tell like trainees when I'm working with, like psychologists in training or therapist in training is, because there's so much pressure when you're in training to like do everything perfectly, and also always remind them like, if they have a positive encounter with you, that is incredible because it means that they can trust the process of therapy, they're more likely to go back when they need it. Like, make that your goal, have a positive encounter with this other human, and it's not about like doing all the techniques perfectly or making sure their depression symptoms are all the way reduced. It's, can you have a human-to-humor, wow, words, human-to-human of authentic, meaningful encounter where they feel like this is something that they want to return to.

PATRICK CASALE: Absolutely. I think that's a testament to doing really wonderful work and that's where the healing and you know, that takes place too, and someone who then becomes much more invested, and then the shamefulness and the stigmatization kind of dissipates. And it's like, "Okay, that wasn't so bad. Like, I can go and talk about this."

And I will say, you know, you mentioned my own therapeutic experience, and that intake was very anxiety provoking for me because I had just gotten these diagnoses, I was still processing. And I was like, really excited to see this person. I've been waiting a long time, she had quite a significant waitlist, and I was like, "I'm just going to wait it out, and you know, I want to see this person." And I would have really, probably been pretty devastated had the response been something different. 

But what happened was, I was just like, "Listen, I want to be really transparent with you. I did just do testing for autism and ADHD. And you know, I did get or receive a diagnosis for both autism and ADHD. And I just want to name that because I'm fearful that you're going to tell me that we can't work together." And she was like, "Oh, yeah, my son's autistic, so you're probably in a good spot." And I was like, "Oh, well, this feels like…"

MEGAN NEFF: That's amazing.

PATRICK CASALE: Yeah, it felt like very much aligned with what I've been working towards. And a couple of good friends in town had given me her name. And I think they probably knew I was autistic. So, I think they did so with, like, the best of intentions in terms of referrals. So, I've been really fortunate. And I know that and I don't take that for granted at all. She actually listens to our podcast and follows you-

MEGAN NEFF: Oh, does she? 

PATRICK CASALE: …on Instagram. So, she's excited for all this stuff to come out.

MEGAN NEFF: Yeah-

PATRICK CASALE: Like, I can't [CROSSTALK 00:11:46]-

MEGAN NEFF: How's that? Like, do you all process that as client therapy of like, and then you see this other side of me because that's really interesting.

PATRICK CASALE: I think that dual relationships, I'm okay with dual relationships [CROSSTALK 00:12:04].

MEGAN NEFF: I wonder if that's an artistic thing because I am too. And I kept pushing my… My therapist and I, we wrapped working together, but we worked together for like four and a half years. And I kept pushing for more dual relationships. And he held the frame of like, and I mean, he's psychoanalytic, it's a little bit more, but I think it's kind of an autistic thing, and may be related to the whole like hierarchy of, we're two humans having a really meaningful encounter, why is it so contained? But I actually understand it therapeutically, also why it's important, but sorry, I interrupted, talk more about your [CROSSTALK 00:12:40]-

PATRICK CASALE: I think that's important to name because I think that's true because now I'm thinking about all the autistic therapists that I know or that I employ who also are absolutely okay with having dual relationships in their lives. And I think it is like the recognition that, yes, this setting is for this, but like, we are also humans who live in a community together and like, there's going to be overlap and like there's going to be potential interaction in other areas of our lives. 

So, I actually think it's great because that's actually a good segue into what to look for in a therapist who's ND affirming because someone who will willingly explore your special interests, I think that's huge, I think that's so so important for someone to like, not just shrug it off, not just try to, like, deflect, or to, you know, kind of transition to a different topic. But if a therapist is recognizing like, "Oh, this autistic client is really into A, B, and C. Like, let's just go with it and see where that goes." Because that's another way to drop that guard down quite a bit.

MEGAN NEFF: Oh, absolutely. Typically, when I'm working with therapists a lot of it's around, like, helping them refine their assessment skills. And a question I'll often ask is, do you feel like you contact them when they start talking about an interest? And by contact, I mean, like, you see them, like, you feel them in the room for the first time. 

And when therapists are like, yes, to me that's like, okay, that's a green flag that we're looking at autism here, is you feel like you're contacting the person for the first time when they start talking about their special interest. 

Before that it's you're asking all those social-based questions like, tell me about your family, tell me about your friends, and you're getting like one-word answers or like, it just feels really, you don't feel like there's a person there probably because most of us are in free state when we get asked social-based questions. And so, if you want to get access to the person you're absolutely doing that through special interests versus those social-based questions, I think that's a huge part of autistic affirming therapy.

PATRICK CASALE: Yeah, I agree. And I think that makes a huge difference. It just feels more real, feels more authentic. You know, you can really drop in then and you can see the personality start to come out too and excitability as well.

MEGAN NEFF: Emotion, which is good for therapy.

PATRICK CASALE: Emotion, right, yes. 

MEGAN NEFF: Like, I just got you… did you see how my effect just like went way up when I started talking about like, especially… because talking about autism and special interests in therapy is your special interest.

PATRICK CASALE: Is your special interest.

MEGAN NEFF: Yeah.

PATRICK CASALE: One of your special interests.

MEGAN NEFF: Yeah, one of my special interests, and my energy just went way up? 

PATRICK CASALE: Yeah, I mean, I think it's so important to follow that. And so often, I think I've been in so many therapeutic relationships as the client where, you know, I am just either going to be like robotic sounding board, rehearsed answers, like, know what to say, versus like, the ability to dig deeper and actually go into processing trauma or lived experience because we're connecting on the same wavelength because you're allowing for me to diverge, where my brain is going, instead of trying to circle back constantly and like, "So, let's talk about this." It's like, "No, I don't want to talk about that right now."

MEGAN NEFF: And to me, like that would be a... if we're talking about kind of red flags of like ND affirming therapists versus not, I think that would be a red flag of someone who's maybe not a great fit. If every time you start talking about something you're excited about, like, the therapist kind of does that with you for a couple of minutes, but then circles you back to, "Okay, and the point of this is… so but tell me about, like, how that makes you feel or tell me about…" Like, trying to redirect it back to the neurotypical-

PATRICK CASALE: And what happens to the typical autistic person when that happens to them? Like, what is your [CROSSTALK 00:16:43].

MEGAN NEFF: What happened? 

PATRICK CASALE: Like, what's the instinct or like the reaction, typically, when someone like does that to someone?

MEGAN NEFF: Well, I'll share my experience. So, I was working with a spiritual director, which is different than therapy, but kind of like, there's a similar back and forth aspect to it. And this was back when I was in the… I no longer identify as religious, this was back a few years. But I was explaining, so Moltmann is this theologian I love and I was really into Moltmann, and he was helping me as a… he's very philosophical, so he was helping me, like, think through a lot of my psychic stuff, as well as my, like, relationship to the sacred. And I was getting really into Moltmann and explaining it because I was reading this, like, 1000-page book at the time. 

And then my spiritual director was like, "Yes, but when you talk about that, where do you feel in your body?" And she's bringing it back to like analytic, and I was like, "I was just telling you how I felt about it by like unpacking who Moltmann is, the ideas I'm engaging with. Like, I literally was just telling you how I feel about it." But then she was bringing it back to allistic speech of emotion words, body words. 

So, I froze in that state. And I like shut down. And I think I went back to like that pre-scripted conversation. It was a requirement of a program I was in when I did it. So, I think all the other sessions after that I would come up with this is what I'm going to say, I just kind of bared through them. I would brace for it because it felt very intrusive attending these visits. 

And I felt very inadequate of like, why are these questions hard for me to answer? I didn't know I was autistic at the time. So, like, why is this so hard for me to answer? Every time I go academic she tried to bring me back. But that's how I disclose my inner world to people is through ideas. And I think she saw that as a defense. And so, was trying to bring me back into emotion language, which is a language that I'm not… That's not how I share my inner world with people. I'm not like, this is how I feel about it. And that's just not my language. That's what happened to me. I froze, and got defensive, and scripted out how I'd make it through the rest of sessions.

PATRICK CASALE: Yep and I think that also, in my opinion, creates some shamefulness internally of like, at least for me, what happens is I shut down, like you just kind of mentioned, and then I started thinking like, "Why the fuck can't I access this? Like, why can't I speak like this or reference this?" And then I get really in my head. And that's what's been nice about my current therapist is she has said things like that before where she's like, "You know, do you want to drop in today or do you want to do this?" I'm like [CROSSTALK 00:19:49].

MEGAN NEFF: Oh, I like that. She's getting consent. 

PATRICK CASALE: Yeah, she always asks and I'm always like, "No, I don't want to do that." And she reads my facial expressions really well. And she's like, "You're not here for this today, are you?" I'm like, "No, I don't want to do that. So, can we fucking talk about what I want to talk about?" And you know, sometimes that is definitely a defense mechanism too-

MEGAN NEFF: Totally, yeah.

PATRICK CASALE: …but at the same time, the how does it make you feel? Or where do you feel that in your body? Like, all the typical therapeutic language, I just can't tolerate it. And it just makes me, I've already checked out then. Like, I'm just going to go into that faking state of just like yeah, and head nodding, and short answers, and…

MEGAN NEFF: Does it feel intrusive to you? To me, it feels so intrusive for someone to ask like where in your body is that or even how you're feeling, it feels intrusive.

PATRICK CASALE: I think it does feel intrusive and I think it's because… And this is, again, just my perspective is like, when you're being asked that, it's like saying the other person doesn't really see you and doesn't really understand your inner world. And that just makes me feel like we're really not connecting. And I'm kind of going to check out. I just don't want to have the conversation anymore. 

MEGAN NEFF: Yeah, yes. I think the reason that I worked with my last therapist I worked with was, well, first, it was the first male therapist I worked with, and I think that worked well for me because, like, all the emotion feely stuff doesn't work for me. And a lot of, gosh, this is so gendered and binary, but I haven't been to any genderqueer therapist before. But the women I worked with who are therapists were very like feely emotion. And I needed someone who's more analytic, intellectual, which I found more easily in a male therapist than I did in the female therapist that I tried. Again, there's going to be a lot of variance there. But for me, I realized working with a male therapist ended up working a lot better. 

And there's plenty of female therapists who are also not feely warm, but I think, okay, I'm going to stop. I'm like feeling myself digging myself into a hole around creating gender stereotypes and I'm going to stop trying to dig out of that. 

Okay, where, oh, this is where I was going with that [INDISCERNIBLE 00:22:07] trail. After the intake, in our first session we had, he didn't start with how are you feeling? He started with what's on your mind. And I found myself opening up, which was not normal for me for therapy experiences. And I realized that after I was like, that made such a difference, that simple question, what's on your mind? Versus how are you today? Or how was your week? That felt invitational versus intrusive. 

And so, I think that's one of the reasons we worked together well for so long was, and again, we didn't know, I didn't know I was autistic. He obviously didn't know. But yeah, I found that a much nicer way of opening a session.

PATRICK CASALE: Yeah, I like that, what's on your mind? I think when you ask the like, how's it going today? Or how's your week? Or how are you feeling? My instinct is always to be like, "Good, I'm fine. You know, like, nothing's wrong." And then I feel myself as we're going through a therapy session to be like, "Oh, this is so wrong, like everything is happening to me right now."

But it's instant instinct to just immediately answer with a short answer and just move on to the next question. And I think that, again, when we're talking about green versus red flags in therapy is really the approach has to really be important. 

And so, talking about green flags, like, let's highlight the good stuff before we [CROSSTALK 00:23:41]-

MEGAN NEFF: Yeah, we've kind of been down on therapists today.

PATRICK CASALE: We're both therapists and we're both shit-talking therapists. 

MEGAN NEFF: I know and there's a lot of amazing therapists out there. Like, there's therapists who come and pay me like a ridiculous amount an hour to consult with me because of one client they have. And like, there are therapists out there who, like, care so much and are doing the work. So, yeah, I was even noticing that earlier. I was like, "Oh, I feel kind of bad."

And I think on social media right now, especially, in autistic world, there's a lot of negative talk around therapists. So, I was even feeling that of like, "Gosh, this is all true and I don't want to be contributing to that narrative of like, all therapists are shit therapists and don't know how to work with us." Because there's a lot do, yeah.

PATRICK CASALE: Yeah, there are. I think all of these conversations are not binary and like these are not black-and-white conversations, and I want to highlight both sides of the coin because there are so many bad experiences whether you're autistic or not autistic. I mean, there's a lot of bad experiences, but there are a lot of wonderfully positive, transformative, empowering, affirming experiences too. And there are a lot of wonderful therapists who are doing the work, who are curious, who are learning as they go, as we all are, and who are willing to show up and have really difficult conversations, but also be as empathetic and present as possible.

MEGAN NEFF: Absolutely, absolutely. Yeah, so let's talk about green flags. What are some that come to your mind when you think about, like, how you steer people or what they should look for? Whether it's like they're doing a search on Psychology Today or they're on the therapist's webpage? What do you think they should be looking for?

PATRICK CASALE: I think, again, language is important. I think that, you know, I want to see what people are using in terms of identity-based language. I want to see, like I mentioned before, are we still using ASD? Are we still using the term Asperger's? Are we really committed to the ABA philosophy and intervention set? I think that I also really want to know about, I personally like to know about therapist's identities as well. So, I want disclosure, like, I really value that. And I think that is really helpful for any sort of affirmative care, but I think those are some green flags that I look for. How about you?

MEGAN NEFF: Yeah, I love that, yeah, someone who's taking their time to highlight this is how I'm socially positioned in the world is obviously thinking about identity in a thoughtful way. So, I think that is a significant one. Yes, agree about identity language. 

And I love that the word neurodivergent, neurodiversity is becoming more widely used, but I do see that sometimes sprinkled on websites, but then it's like, interacting with the content or books, I've read books where they use neurodiversity, but then it feels like they've just like substituted ASD for neurodiversity or neurodivergent. 

So, I also, like, I think, like paying attention to the energy you feel when you're reading about a therapist webpage. Again, I'm very interpersonal. And so, I really trust, like, what is happening to you, when you're on this person's site, energetically, in your body, what are you feeling? But paying attention to just how you feel when you're reading about this person and interacting with what they're putting out in the world?

PATRICK CASALE: I want to know, also, like, therapists takes on self-diagnosis. I think that's-

MEGAN NEFF: Oh, yeah, yeah. 

PATRICK CASALE: You know, I think that it's definitely a pretty controversial topic in that world. But I always want to know, what do you think about self-diagnosis? 

MEGAN NEFF: That's a great question, yeah. 

PATRICK CASALE: Yeah, because I recognize my privilege. Like, I'm able to go and get testing done and, you know, seek out therapy that I want to seek out instead of just what's in front of me, and so I want to know about that. 

I want to know about their, you know, you were mentioning Karissa before, and her web page, and their resources that they have on there, and all the frequently asked questions, and ways that they can help guide through. I want to know about thoughts on stemming during sessions. And like if they're able to have any sort of sensory soothing tools? How are we going to set up? Like, how are we feeling about eye contact, even like, in terms of virtual sessions, or in-person sessions, but virtual for sure?

Like, my therapist always encourages me and she'll say it like when she can tell I'm really struggling with eye contact in general. She's like, "Please feel free to, like, look around the room and like, do whatever you need to do, we do you. I'm right here, but you don't have to look at me at all." And at first that made me feel like really uncomfortable because I'm like, looking like this and like [CROSSTALK 00:29:15]. I'm like, I could sense the discomfort, but in reality, like, she's just like, "Okay, it's fine. Like, do whatever you need to do." And I think that helps really feel really affirming as well.

MEGAN NEFF: Yeah, yeah. That whole, like, are the neurotypical scripts kind of being followed in a way where it's assumed like, okay, this is how we do it. We sit down, we look at each other, we talk. Yeah, absolutely. 

So, for the last two years since COVID started, I've been doing phone therapy with my therapists, and I'll go out, and walk and I found I really liked that because I could get into my emotions a little bit easier if I was walking. And I would say about half the people I work with do phone therapy, and a lot of them walk during it because there's something that's regulating about walking, there's none of the eye contact. So, I think even asking about, like, what's your frame of therapy, and I realize it's really different around the world. In Oregon, all medical providers who are wearing masks and mask therapy it's just so hard, important for health reasons and so hard for therapeutic reasons that a lot of therapists in Oregon are still doing teletherapy. I don't know if it's what it's like there.

PATRICK CASALE: I'd say the southeast stopped caring a long time ago. 

MEGAN NEFF: Sure. 

PATRICK CASALE: But thankfully, Ashville-

MEGAN NEFF: Did they ever care?

PATRICK CASALE: …is a bit more progressive than most of the southeast. But we're doing a hybrid mix. Our practice is predominantly telehealth. So, like, telehealth, for the most part. I've always done telehealth therapy with my therapist. I've never met her in person. And she'll encourage that too. Like, if she can tell that I'm starting to get dysregulated she's like, "Get up and walk around your kitchen." Or like, "You know, go walk around the house and come back." Or, "Do what you need to do to regulate yourself."

And I really appreciate the permission to do that instead of feeling like shameful about it or like, are you going to tell me to sit down, or that I'm being distracting? Or like any of the things that I've heard throughout most of my life?

MEGAN NEFF: Yeah, yeah, yeah. And I think that can be really healing in a therapy is when the therapist is helping you, like, think through what do you actually need in this moment? Especially, for maskers, we're so used to suppressing our needs in any given moment that A, it's hard for us to access what we actually need, let alone to do that in front of another human. So, I think therapy can be a really powerful practice ground of [INDISCERNIBLE 00:31:52] with another human. I have some sort of sensory or regulation needed in this moment. Can I practice, A, checking and figuring out what the hell it is I need and B, actually doing that in front of another human?

PATRICK CASALE: Yeah, yeah, I think that's like the epitome of safety, is if you can feel comfortable enough to unmask and really have someone else also acknowledge, and see what, and understand what you need in the moment. And without that, that shame or that quick desire to like, immediately flip that switch and be like, "No, everything's fine. Like, I'm okay." Because we do that so often in our day-to-day where we have to act, or present a certain way, or show up a certain way. And I think therapy can be a really beautiful place to kind of just let that shit go and just like, really show your true self. And I think that is just so hard to do on a consistent basis.

MEGAN NEFF: Absolutely, absolutely. Especially, when you're autistic and have been actively working to not show your true self for years and years, yeah.

PATRICK CASALE: Yeah, it's so deeply rooted, right? 

MEGAN NEFF: Oh, go on.

PATRICK CASALE: Sorry, I'm just-

MEGAN NEFF: No, go ahead. 

PATRICK CASALE: I was just going to say it's deeply rooted. And, you know, I think having an ND-affirming therapist, that's another part of it, that's another green flag is the acknowledgement of how much energy goes into masking and how challenging it is to really reveal like, what's actually happening beneath the surface. So, I really appreciate that perspective and that ability as well.

MEGAN NEFF: Absolutely, absolutely. Okay, so we've talked a bit about like, language and characteristics of the therapist. I'm curious, I get this question a lot, and I've got a few thoughts, but I'm going to put you in the hot seat first. Do you think there's certain therapy modalities that work better for autistic people?

PATRICK CASALE: Yeah, I do. I will say what I think doesn't work. But this is, again, I'm always going to defer to you when we're talking anything clinical because that's your jam. I will always admit that I have not done the research and the work that you have done. 

And I think for myself and for a lot of autistic folks EMDR, brain spotting, that stuff is really challenging. And I also think CBT is also really really hard, the concrete, like, regimented this is what you do, this is what you do, this is what you do, I think DBT can be supportive. I love IFS, I love parts work. 

MEGAN NEFF: Yeah, same.

PATRICK CASALE: I think that is so fucking powerful and you can really tap into those special interests with parts work. I had such a hard time accessing it like, visually if you were like, "Imagine this boardroom and your parts are there, and they're like communicating." I'm like, "What? No, like, that does not work."

But my therapist knows I love Lord of the Rings, so she's like, "All right, so imagine we're at that scene in the fellowship of the [CROSSTALK 00:35:07]-

MEGAN NEFF: That's amazing. 

PATRICK CASALE: … where everybody is coming together, and the dwarves, and the Elves, and the wizards, and the hobbits, and who's doing what?" And I'm like, at first, I felt so fucking nerdy. And I was like, "Oh, this is making me so uncomfortable." 

But I've really been able to access so many different things when you can drop into that world, and to be able to use your special interests in a way where you can feel more connected to emotions that are happening beneath the surface. I think that has been unbelievably life-changing for me.

MEGAN NEFF: Yeah, yeah. I cannot agree more. I love IFS. I love it for autistic people. I will say, I don't know if you're seeing this out on the East Coast, have you heard of plural systems? 

PATRICK CASALE: Mm-mm (negative).

MEGAN NEFF: It's kind of, oh, gosh, why did I say that? Now I have to try and explain it. So, I would say it's on the DID spectrum, dissociative identity spectrum, when in learning about plural systems what I find is a lot of people who identify as having a plural system, they have more conscious contact with the parts, but it's different than parts work. So, that's the one thing with IFS, I'm like, I love IFS, but then if someone comes in, and they're experiencing, like, they're identified as a we, so people with plural systems often will identify as being plural. And from a affirming lens of like, this isn't something I'm trying to fix about myself, I'm trying to figure out how to integrate these parts. But that's the one thing that I think can lead to some confusion is when you're doing IFS work, but if you're working with a plural system, what the therapist might be conceptualizing and what the person's bringing in, there's going to be a little bit more to navigate there.

And I've seen some CEs come out for working with plural systems. It's so new, and it's nothing that's in the DSM yet. Okay, that was a… I'm like rabbit trailing today.

PATRICK CASALE: [INDISCERNIBLE 00:37:15] Megan and her clinical work, that's right up the alley, so thank you for that.

MEGAN NEFF: But yeah, I'm curious what you said about EMDR. I have wondered about that. I've heard some autistic people talk about that being helpful, but it makes sense to me because it's such an isolated memory you're working with, and our brains are so divergent. So, that actually intuitively makes sense to me.

PATRICK CASALE: Almost flooding that happens too with the EMDR. There's a lot of flooding and when you're bringing back that very specific memory, and I've always found that and, you know, this is just anecdotal. So, this is really not evidence or research-based whatsoever. But what I've heard so often is that it's just so hard with the eye movement and constantly like, flooding yourself with memory, and then being able to access. And I think that for myself I shut down immediately. I've tried it a couple of times, but I've also heard about ND-affirming EMDR starting to come to the surface too, but I have not participated in it. I kind of got turned off early on in my life.

MEGAN NEFF: Yeah, I've never tried it, I'd be curious. I think I probably would not like the flooding aspect of it. It's so experiential. I think that would be hard for me.

PATRICK CASALE: That's the hardest thing I think is the experiential piece. And that's what was hard for me about brain spotting too, I don't know if you've done that, but like-

MEGAN NEFF: I haven't.

PATRICK CASALE: … I did the brain spotting training and I could not access like, you know, you're doing the practicums, and they're moving, you know, the thing back and forth, find the brain spot, okay? And then like, what are you experiencing? What are you accessing? I'm just like, numb, flat, dissociated, nothing. And when that happens to me in therapy I get so frustrated with myself.

MEGAN NEFF: I mean, just you hearing that it makes me think of all the time someone's asked me how I'm feeling and I can't answer like, and all of the situations I've been in where like I'm in a situation and someone's trying to evoke an emotion, especially, growing up religious, I was in that situation a lot. But then also in therapy training, and being like, I feel like I'm supposed to be feeling something right now and I'm not and then I get in my head about that. Yeah, yeah. So, I think that was-

PATRICK CASALE: I just [INDISCERNIBLE 00:39:29] I was like, "I want to get through this practicum." Be like, "Yeah, I'm feeling this thing, and like can we fucking move on? This is awful."

MEGAN NEFF: Totally, totally.

PATRICK CASALE: How about you? Like, what do you think works and what doesn't? So, do you feel like IFS is probably up there?

MEGAN NEFF Yeah, I really like IFS for… especially, and I think, for multiple neurodivergent people, like I'll talk a lot about like my ADHD part and my autistic part. And so, I love the language of it. I think it destigmatizes and de-shames because it creates a little bit of distance from parts. So, like, this part of me wants this, this part of me wants this. 

So, also, the ability to bring in more complex thinking, which is harder for a lot of us. We are more prone to that rigid thinking. So, I think that provides a concrete way and a visual way, which works really well for the autistic brain to do some complex, nuanced thinking. So, yeah, I love IFS. 

Other ones, I do like act for a lot of autistic people, not for everyone, but a lot of people. I responded well to, like, learning act as a therapist, and I use a lot of that sort of mindfulness in my day. It's different than CBT in that you're not trying to change the thoughts, you're changing your relationship to the thoughts. So, I think it honors the complexity and the existential aspect of a lot of our thoughts while helping you to distance from them enough that you can kind of hold on to yourself and ground yourself. So, that's what I typically also think can work well. 

And then, I really like interpersonal stuff because we're so often trying to figure out what the other person's thinking, that if you can do that in the room therapeutically, I think it can be really healing. It takes quite a bit of, like, ego strength or psychic strength to be able to do that. So, maybe doing some other work before you do that. But interpersonal therapy or I really like relational psychoanalysis, traditional psychoanalysis. I'm not sure how I feel about that. For autistic people, it might be too much of a blank slate of the therapist. 

Relational psychoanalysis is the third wave and the assumption is the therapist and you are always co-creating the reality, and that the therapist is not off the hook. They are part of the dynamic as well. But we get to talk about it, we get to understand it, we get to look at it together with curiosity. 

I think that sort of living lab of relationship, can we understand what's happening between the two of us can be so so healing because so many of us have relational trauma and confusion coming into therapy. So, I would say those four relational interpersonal act in IFS and DBT, I think, has some good strategies as well. But those would probably be my favorite ones for us.

PATRICK CASALE: I like the relational psychoanalysis. I've actually never heard of that third wave. So, that's pretty cool. I couldn't deal with the blank slate psychoanalysis, like, that was a little challenging for me to be like what the fuck is happening right now?

MEGAN NEFF: Yeah, I don't think it would cultivate enough psychological safety in the room to be able to do work because, partly, as a high masker we're always trying to tune to the other to figure out what does that person want me to be? So, with a blank slate, it's like we're flailing. So, if you could talk about it, though, so like my therapist who was relational psychoanalytic, he did hold kind of a blank slate in the beginning because he could tell how badly I was trying to figure out who he was, so I could figure out who to be. But we were able to talk about it, we were able to talk about what was happening around my, like, desire to please him or my desire to adapt to like, you know, be the ideal patient. 

So, I think that if the blank slate is there, but it can be talked about, I think it's okay, but if it can't be talked about, if it's like, "Oh, well, what is it bringing up for you that you can't read me?" And if it's always reflected back to…

PATRICK CASALE: Yeah, that would surely ensure that I would never come back to that person. I would be like, "Yep, all right, guess I'm done today. In 43 minutes, I'm getting the hell out of here and I'm not coming back, so…"

MEGAN NEFF: Yeah. 

PATRICK CASALE: What are your thoughts on CBT for autistic folks?

MEGAN NEFF: Yeah, I agree with you. I think it's so linear and logical. And our brains tend to be so divergent in context, like high context in the sense that, well, that thought in this context made sense, but it's pulling thoughts out of context to work with them, which just doesn't work for most of us. It does work for some though. 

And I think, like, I've worked with some people who are autistic and not autistic, ADHD, who are maybe, like, engineers or coming from a really linear logical background who actually really like it. So, I wouldn't do a blanket slate statement of it's always bad. I do think, in general, it doesn't work well. That said, there's some things I pull from CBT like having a list of common cognitive distortions and just being able to identify like, oh, my brain's doing that right now. Now, I'm going to go in and try to change my thought. But like I'm just mindfully noticing my all-or-nothing thinking filters on right now. 

I think that sort of thing can actually be really helpful. But again, that's taking a CBT idea and then using it mindfully versus let's try and change your thought you're having right now, which I just think is really invalidating for a lot of us.

PATRICK CASALE: I'm glad that you named that about the folks who are maybe autistic, but not autistic, ADHD, and how if you do find yourself in like, engineering, or software design, or something that is really cognitive heavy, where your brain is just thinking very, very, very rigidly and in linearly, and thinking out these patterns, I think CBT probably makes a lot of sense in that regard. So, I'm really glad you named that. That certainly does not work for me. 

MEGAN NEFF: Me either.

PATRICK CASALE: Also, in general, like thought stopping to me is fucking mind-boggling. Like, just stop having this thought. It's like, that is infuriating to me. But I agree, like, if you can pick out pieces of all of these theories of modalities, I think they can all be applicable and useful. 

And, again, just want to reiterate to everyone listening that none of this is blanket statement stuff. Like, there's always going to be little pieces that work for you. And you may have had great experiences with some of this stuff. And you may have had horrible experiences with some of this stuff. Ultimately, I think it circles back to what you named initially. And it is the rapport with the therapist. Like, if the rapport is there, you're going to be more willing, probably, to try new techniques, and you're probably going to be more open to them. If the rapport is not there, you're going to shut it down. 

And I certainly have done that. Like, that person could be the best therapist in the world, but if the connection, and the rapport, and the relationship is non-existent, whatever you're trying to get me to do, or try to do, I am going to not be open-minded to it. I'm probably just going to be like, "Yeah, I'll try it." And again, in my head, I'm never coming back here and I'm done with this, so…

MEGAN NEFF: Yeah, yeah, absolutely. I can't remember where I read this or heard it said, but someone talks about how, like, there's more diversity within autism than like, autistic to allistic. I'm not quite capturing what they were saying. But essentially, the idea that, like, autistic people, there's so much diversity and that's partly why someone's like, "What's the best therapy for autistic people?" It's like, well, there's a lot of different kinds of autistic people and what works well for one autistic person might not work well for another. 

So, I love how you how you said that of, well, it really depends on the person and their context and comes back to that human relationship. Is this someone that you can have an authentic encounter with?

PATRICK CASALE: Yeah, and I think for a lot of you listening, and myself included, and I imagine for you, Megan, like, you're going to have multiple therapists throughout your life, probably. You know, you're going to go through these phases and chapters of healing, and learning, and growth, and transformation, and what you preferred, and liked, and enjoyed in the therapy room five years ago is probably very different than today. And the next therapist that you see will probably be very different than the one you're seeing right now. It just happens. And that's really common to have different phases of your mental health journey. 

So, you know, if you're feeling any sort of way about that, I just want to really validate that you're going to have a lot of people in your life who are probably going to come in and out, and some that are going to stay longer than others.

MEGAN NEFF: Yeah, absolutely. Should we do our awkward goodbye. 

PATRICK CASALE: Well-

MEGAN NEFF: I can feel the energy of we're wrapping up.

PATRICK CASALE: No, no, no, I'm being kind… I'm like, trying to think about something real, like we've covered a lot of ground, but like, have we talked about what not to look for? Like things where people really pay attention to and kind of acknowledging this is probably not going to be a good fit. I guess it could be everything that is opposite of what we've talked about and what we should look for, which seems pretty easy to state that. But just my thought right now is, those of you who are concerned about, or confused about, or overwhelmed with the process of finding a therapist, there are ND-affirming directories out there, too.

MEGAN NEFF: Yeah, I've got several... We'll put them in the show notes, but I've got several on my resource page on my website. And so, if you go to neurodivergentinsights.com, I think /resources and scroll to the middle, I've got like four or five directories. There's even one for the UK, which is awesome.

PATRICK CASALE: Yeah, that's awesome.

MEGAN NEFF: And they're growing. Like, they're growing daily. And more and more therapists who are neurodivergent are coming out as neurodivergent. So, like, also, I mean, pretty much every neurodivergent therapist right now has a long way list, but there's more of us, and it's easier to find us.

PATRICK CASALE: Yeah, that's a great point. I think that for those of you listening, Megan's website has so many great resources and that can be a really helpful way to do that. And if you're not in an urgent crisis, you know, if you find someone who you really want to work with, and they have a waitlist-

MEGAN NEFF: Get on.

PATRICK CASALE: …I recommend just get on it. You know, you never know how quickly that's going to move and it is worth the wait if you are waiting for someone specifically who really gets it, or who really can help you, or support you through your journey, and validate, and affirm because, otherwise, you're scrolling through Psychology Today, and you don't know who the fuck you're calling most of the time. I mean, it's just like, "I'm going to call the first 20 people I see and then whoever calls me back first is going to be my therapist." And that doesn't always lead to great results for the therapist or for the client.

MEGAN NEFF: Yeah, yeah. And one thing, I think autistic people might… I know I would be this way of like, it would feel wrong to be on multiple waitlists because it's a waitlist, I don't know, maybe you're not like that. But so, I like to explicitly tell autistic people, you can be on multiple waitlist, that's actually really normal, and you should be on multiple waitlists. So, if there's a few therapists that you're thinking they might be a good fit for me, it's totally normal to be on multiple waitlists. It's part of why waitlist can go faster because by the time we call someone on the waitlist, maybe they've already found a therapist, often is the case. 

PATRICK CASALE: And you're not going to hurt the therapist's feelings by being on multiple waitlists, deciding to go with whoever comes available first. That is absolutely okay. And it's totally normal, it happens all the time, the therapist is not going to get their feelings hurt by that, they're just going to move on to the next person on the waitlist. So, I know a lot of the times we can feel some guilt around stuff like that, but totally part of the process.

MEGAN NEFF: Yeah, absolutely. 

PATRICK CASALE: Cool. Well, I hope this was helpful for everyone. And we will continue to have conversations around this because I think this is a very important topic for those of you who are looking for support. And again, lots of resources out there and we'll put those in the show notes so you have easy access to them. 

And we will plan on seeing you next week. So, we have new episodes coming out all the time on all major platforms and we will see you later, bye.

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