All Things Private Practice Podcast for Therapists

Episode 63: Autistic, ADHD Therapists & Entrepreneurs [featuring Megan Neff]

Show Notes

Autistic, ADHD Therapists and Entrepreneurs…

What are the first thoughts that come to mind when you hear the combination of those words?

Is it connection, empathy, passion, creativity, and innovation? Is it struggles with picking up social cues, energy depletion, over-commitment, and sensory overload?

The answers are broad and vary from person to person, but it’s fair to say that in many cases, it’s a mix of all of the above (and maybe a few more things).

In this episode, I talk with Megan Neff, psychologist, an expert in neurodivergence, private practice owner, author, and creator of the Instagram account @Neurodivergent_Insights.

Top 4 reasons to listen to the entire episode:

  1. Hear from two successful autistic, ADHD Therapists and Entrepreneurs who share their experiences of navigating entrepreneurship after receiving an autism diagnosis in adulthood (which is more common than you may think)
  2. Learn why emotional tone and picking up on social cues are NOT the same thing
  3. Understand the balancing act between ADHD and autism and how it plays an integral part in entrepreneurship and therapy.
  4. Learn ways to protect your energy and manage time to prevent and manage burnout.

Whether you have a diagnosis or not, this episode is full of first-hand accounts of experiences that challenge the stereotypes and stigma around autism and ADHD as therapists and entrepreneurs.

More about Megan:

Dr. Megan Anna Neff has a doctorate in clinical psychology and is currently a psychology resident in private practice where she specializes in working with neurodivergent adults and provides neurodivergent affirming assessments. They are a parent to two neurodivergent children and in an inter-neuro partnership. She is a late-in-life diagnosed autistic-ADHDer who is passionate about educating the mental health field on non-stereotypical presentations of autism and ADHD. 

Neff has co-authored two books, published in several peer-reviewed psychological journals and serves as a peer-reviewer for APA journals. She has a passion for research and for translating research into visualizations. You can also find their work on Instagram (@Neurodivergent_Insights) where they turn peer-reviewed academic articles into visual pixels one post at a time.

Megan's Website:

Megan's Instagram: @neurodivergent_insights


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A Thanks to Our Sponsor!

I would also like to thank The Receptionist for iPad for sponsoring this episode.

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The Receptionist for iPad is the highest-rated digital check-in software for therapy offices and behavioral health clinics, used by thousands of practitioners across the country.

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The software sends an immediate notification to the therapist when a client checks in, and can even ask if any patient information has changed since their last visit.

Sign up for a 14-day free trial of The Receptionist for iPad by going to, and when you do, you’ll also receive a $25 Amazon gift card.



PATRICK CASALE: Hey everyone, you are listening to another episode of the All Things Private Practice Podcast. I'm your host, Patrick Casale, joined today by friend and colleague, Dr. Megan Neff. And Megan has been on the podcast before where we were talking about autism and ADHD. And today we are going to talk about the experiences of being autistic, ADHD therapists, and entrepreneurs. 

And we're both kind of tired today. Checking in before we started recording we're both kind of just rundown. So, we're going to see where this goes. And I think that's kind of divergence in a nutshell. So, Megan, I'm really happy to have you on again.

MEGAN NEFF: I'm really excited to be back. I really enjoyed our last conversation and found it meaningful, and just felt easy to dive in with you. And I don't know what we're going to talk about, but I trust it will be interesting and meaningful.

PATRICK CASALE: That feels like high praise. I feel the same way. And I was telling Megan before we started, I intuitively thought about you before this episode, and I was like, "I feel like Megan might have a lot going on right now." And I could sense that. Do you ever feel like, in terms of intuition, autistic people being able to sometimes read that without even being in connection for a long time?

MEGAN NEFF: Yeah, yeah, I do. I often say or think, you know, I think probably in past, you know, if we would go back hundreds of years that a lot of autistic people would have been shamans, or prophets, or kind of spiritual leaders, kind of visionaries. I've certainly had experiences that are, like, unexplainable, and will just know things about people or know things. And I see that a lot in my clients too, that sort of energetic knowing.

PATRICK CASALE: Yeah, and I think that makes a lot of sense. And I have always thought about that, you know, in terms of, you know, not wanting to jump out and like try to assume or speak for someone in some way, and you know, but ultimately, really having a very deep understanding, and sort of unexplainable connection or intuition into what's happening in that person's experience or that person's world. 

And that happens a lot as not just a therapist, but an autistic therapist. And, you know, I've talked before about how there's this misconception, and I think you and I talked a little bit about this last time too, this misconception that you know, autistic people are not empathetic [INDISCERNIBLE 00:02:39] connected to other people. Like, that's so badly-off base. And yeah, I mean, I'm just thinking about that in terms of being a therapist, too. And then, you know, yeah, tell us your thoughts about that, in general.

MEGAN NEFF: Oh, so many thoughts. I mean, this was the reason my husband and I, and then my therapist and I, like, initially had a really hard time thinking about me as autistic. The first time I was like, "I think it's me." Right? Because we're trying to figure out where did my daughter get it from because typically, one of the parents is, not always but... And my husband is like, "Well, we know it's not you." Because like, I'm craving an emotional connection. I'm very emotionally aware. 

And so, that was huge for me once I learned that, like, there's a difference between picking up emotional tone and picking up social cues. And that took me a while, like, okay, I feel so autistic except for this piece. 

But then when I realized I had struggled with it, I just assume people want their emotional tone observed and commented on. So, like, you know, talking with a fellow, like, when I was in training I remember an encounter where I think we're in the hallway, and I was like, "You seem sad." And I meant it empathetically, but she obviously got very awkward. And looking back, I think she was… and we were probably having one of those like, "How are you?" She's like, "Good." And I was like, "You seem sad."

And she was probably not wanting that drawn out, but I wasn't picking up the verbal cues of like, "I'm sad, but I don't want to talk about it." And so, that's where I realized, oh, okay, there is a difference here. And it isn't interesting, like, people in my life, like, going through high school and college always felt pretty… a lot of people felt quickly known and understood by me because again, I would like know what they were emotionally feeling pretty quickly. But yeah, those social cues of not everyone want that pointed out, that part was totally missing to me.

PATRICK CASALE: That's such a good delineation, too. And to kind of point both of those things out because I think if you took a step back and started to think about it that way, that makes a whole lot of sense, where you can be really not just intuitive, but receptive, and really, you're absorbing that person's energy too, right? And like, being able to witness it as if you're in their own experience. But you're right, like, how many people often want to be like, "Yeah, I want to talk about this thing that you're picking up without prompt?" And-

MEGAN NEFF: Right, it can feel so intrusive.

PATRICK CASALE: Right. And I think maybe for myself, I don't want to speak for you by any means, in terms of your experience, like, when it's found to be intrusive I can almost be like in that RSD or like have this projection of like, "Oh, shit, I just did something really wrong here." Like, I-

MEGAN NEFF: It's true.

PATRICK CASALE: Then you start to really get into your head of like, "I don't know how to socialize."

MEGAN NEFF: Yeah, yeah. And I mean, for me, that's why I became a therapist, I'd be curious about yours. And this is how I navigated social spaces. I would be drawn to the people who did want to have those conversations, and who were very existential, and I would just not really hang out at the surface. I would always find someone, go deep, but that led to other complications. But it meant I didn't really resonate with the heavy social struggles because I would just find people go really deep, and then, move on. Okay, I am fragmented today. I can like feel my thoughts turnaround. 

But another thought I had that I'd be curious about because I had this experience in training and I remember really wanting to ask about it. But I was like, "This sounds really weird." I remember sitting with a client, has gone through informed consent, and all of a sudden, my word started getting really bubbly and I got really foggy. And that's not typical for me. 

And then, I kind of continued to have that fogginess throughout the session. And over the course of our work together, I realized this was someone who had undiagnosed PTSD and was kind of low-key disassociated much of the time. So, for me, if my client starts fogging out, I start fogging out. And so, I know before they even say anything like, "Oh, they've just hit something emotional." Because I start feeling like heaviness over me. And I even experience that over Zoom therapy, which is wild to me. 

I'm so curious, do you have experiences like that as a therapist, just like intense, intense mirror neurons where you're kind of viscerally feeling what your client's feeling? 

PATRICK CASALE: Oh, yeah. All the time. And it still baffles me at times where like, if I'm feeling more energized, which to be honest with you, is not often. My energy level is pretty baseline low. But if I'm having a more energetic day, and then I step into an interaction therapeutically, where that client has a lot of heaviness about them, and you can really sense that intense struggle, I will absorb that too. 

And then, you're right. Like, that fogginess exists. I'm like, stumbling through words, but I'm also trying to, like, make coherent thoughts happen, and have things together that I usually do like that. And I'm like, why can't I think of what I'm trying to say right now? And I mean, when we think about that, I mean, it seems so counterintuitive, right? But ultimately, it really does come back to that portion of the energy absorption, right? And like, maybe you're just picking up on that energy, even like you said, through a Zoom meeting.

I think I find it even more intense through Zoom meetings, to be honest with you because I spend so much more time like tracking in Zoom than I've done in person where it's very obvious, like what someone's body language is doing.

MEGAN NEFF: So, like, there's more hypervigilance when you're on Zoom?

PATRICK CASALE: I think so. Like, I'm definitely trying harder to make eye contact on Zoom. I'm trying to like pay attention to my client's like body language and shifts because you know, I can only see where you stop or whatever, and I'm trying to really get a sense of what's happening for that person. And then you're listening much more intently to like that inflection in voice too, and like, [INDISCERNIBLE 00:09:12].

But I think all of your energy is also being like really focused in on trying to be as aware as you can. And then when you're picking up on that energy, I mean, you can almost go blank as if, like, do I even know what the fuck I'm doing right now? Like, I don't even know if I'm either client or the therapist.

MEGAN NEFF: And yeah, yeah. Especially, if I'm, you know, kind of working through something pretty intense with someone, and yet, like you're saying, I'm in that same space with them. You're right. It's like, okay, I'm the guide here. But I'm also struggling to put words into a sentence. And again, it depends on the relationship, but I've started being more interpersonal and self-disclosing with it and using that of like, I'm feeling this right now. Does that mean anything to you? Or I'm with you and I am metabolizing this. I'm not as eloquent with my words if I'm metabolizing it, but…

And that's given me a lot of freedom of kind of naming in the interpersonal space, this is what's happening, because before I would try to push through and I would try to, like, make articulate sentences, and then, feel guilty when I wasn't able to do that. Like, oh my gosh, I'm such a confused therapist right now.

PATRICK CASALE: How do your clients usually respond to that? I imagine that they're really receptive to that.

MEGAN NEFF: Yeah, I think in general, I mean, and I like interpersonal work. It's probably my favorite. And I wouldn't make a comment like that unless the relationship supported that sort of work. So, in general, I think it helps create safety. 

You know, it's interesting. So, it's interesting, on the other side of the couch, right? I've worked with my therapist for about four years. And we've reflected now, because we didn't know I was autistic when I started, like, how did I feel different as a client? What was your experience of me? And one thing he commented is, "You know, you pulled for the interpersonal right away."

And I tend to notice, one way or the other with my autistic clients, like either they really need to know how I'm holding them in mind. And I think that creates psychological safety because we're often trying to figure out how people are perceiving us or they're absolutely uninterested in how I'm thinking about them. But it tends to be pretty extreme, one or the other is one thing I've noticed. I'd be curious if you've noticed anything similar?

PATRICK CASALE: Yeah, for sure. And I, you know, circling back to like flipping the couch around, I noticed that about myself, too. And I do think the psychological safety is paramount there in terms of being able to do that interpersonal work. I just know, like, I'm just thinking off tangentially now, like, going for testing and the guy asking me like or telling me that he knew I was autistic because I didn't ask him about the guitar on his wall and ask him if he played music. And I was thinking, like, "I don't really fucking care if you play musically." Like, I don't get the qualifier there. 

But it almost brings me back and this is how fragmented I am right now to what you were saying about, like, in college, deep conversation going right into it. Again, you and I talked about this, and we talk about this a lot. Like, I don't want to have those artificial surface-level conversations. So, why would I do that? Like, "You have a guitar, and well, do you play music?" Like, the answer is clearly yes or it's no, and I don't care if it's yes or no. 

But I do remember social situations in college. You know, I would start to like, go back to those places where I was very often having conversations with people who were probably either homeless or housing a displaced at the time, and like, really engage with them, and checking in on them when I would be downtown. And my friends would make fun of me for that. They'd be like, "You know, you're always talking to like the weirdest human beings. And those are people you like to have conversations with." And I just always felt like there was some like, there was less vulnerability there in terms of being real. And I just really hated having like the artificial conversation. 

I was just in a conference in Hawaii. And you know, it's interesting as you develop a following that people think they know you even though you don't know them, and [CROSSTALK 00:13:26]-

MEGAN NEFF: Happens.

PATRICK CASALE: …and they'll be like, making eye contact with me as if I definitely know who they are. And I'm looking at them, like, I definitely don't know who you are. They're like, "Hey, it's me." And I'm like, "Oh." "And I listen to your podcast, I'm in your Facebook group." I'm like, "Oh, okay. Yeah, thank you so much." 

And then when it shifts to like, "So, how's it going? Like, how long have you been here? Like, what are you looking to do?" And I'm like, "Oh, fuck, I need an exit strategy". And I'll like-

MEGAN NEFF: Oh, yeah, yeah. 

PATRICK CASALE: [INDISCERNIBLE 00:13:51] being rude, but also, how do I do this [INDISCERNIBLE 00:13:55] purposes?

MEGAN NEFF: Yeah. Oh, and that's tough. Especially, because it's they're kind of admiring your work and you're not wanting, I imagine, to kind of rupture how they are seeing you, but oh, yeah, I hate those conversations so much.

PATRICK CASALE: I hate them. And I've gotten better, you know, since diagnosis and learning more about who I am and how I process everything like to be able to at least name it from times where I'm like, all right, I'm peopled out like I do not [INDISCERNIBLE 00:14:26]. But that stuff is tough. [INDISCERNIBLE 00:14:32] back to being a therapist, though, it's interesting because, you know, if you're talking about like, the double empathy bind, or just thinking about mirroring, and thinking about how autistic people are so vigilant in terms of tracking everything and absorbing everything, I just think it's another way to combat the narrative that autistic people are not empathetic, and are not caring, and kind of not [CROSSTALK 00:14:57].

MEGAN NEFF: Oh, yeah, yeah. I mean, that's just such an unfortunate stereotype. And I think it's a stereotype that prevents a lot of people from getting diagnosed. And it's still a stereotype widely held within the mental health professionals, right? It's like, oh, this person can't be autistic because they can have small talk or because they have empathy. Whereas a lot of us have hyper-empathy. 

And what do you think of the, I know, there's this theory out there that because we tend to see hyper empathy or hypo empathy, that hypo empathy is kind of a defense against hyper empathy that develops through the course in someone's life. What do you think about that idea?

PATRICK CASALE: Yeah, I mean, I can see that being more of like a protective factor for sure in terms of navigating social situations and relationships, and there's so much trauma involved, too, right? Like, in terms of what we're talking about, and also, in terms of feeling safe and able to be connected with people, not just their struggles and their pain, but just in general. So, what are your thoughts on that?

MEGAN NEFF: On the as a protective? Yeah, I mean, I think of it as kind of like a shield that people... So, there's a metaphor I really like. It's a bit psychoanalytic. There's this idea called the skin ego. There's no way I'm going to be able to articulate this because it's very analytic, and I'm very fragmented. But it's the idea, it's the first ego. It is how we learn what is us and what is other. And there's a few essays out there, mostly, from European authors who have talked about autism and skin ego. And I find this really interesting. I've written a brief reflection on this of how I feel like I have porous skin. Like, I don't feel like I have a contained skin ego. And so, I create artificial skin to protect from my porous skin because everything gets in, people's emotion, sensory, smells, and it hits me to the core. 

And so, for me, my artificial skin I've created are things like routine, special interests, wearing really comfortable clothing, literally, artificial skin. And I think for some people, I mean, so my hypothesis, and I hold this loosely as a hypothesis, is that kind of all autistic people start with porous skin. Get I'm speaking metaphorically, not literally. 

Some people develop artificial skin to work with it, some people don't. And they're just constantly bombarded by the too much ness of the world. Some people develop armor, and so, the world just bounces off of them. And I think that's the more stereotypical presentation of autism is kind of flat, emotionless, empathy-less, hypo sensory, and in my mind, that's when people have developed armor to protect the porous skin. And so, it's like a metallic thing that bounces off then puts up the world.

PATRICK CASALE: I like that. And I think you actually describe that really well. I think that makes a lot of sense. And, I mean, it has to be learned so early on too, in terms of like, what you're able to tolerate, and not tolerate, and what feels really uncomfortable and disruptive, and especially, growing up without the language or without the ability to really communicate or process, and without the education, you're figuring out a way, right? Like, you're figuring out a way to protect yourself. And some people really have to get firmly entrenched in that as well in terms of being able to set that boundary and just protect that.

Because I was noticing the other day, I mean, I've been really worn down, I've talked about, you know, having surgery in a month and you know, preparing for that. So, there's a lot of emotional stress going on. 

And I just noticed, like, I do a pretty good job navigating my day-to-day and like, moving through the world as best as I can. But I was noticing everything. Like, smells [INDISCERNIBLE 00:19:12] times a million and they're already intensified. Like, [CROSSTALK 00:19:16] more intense, like, having conversations with people was painful. And I was just thinking like, "How in the fuck am I supposed to be a therapist, or a coach, or anything [INDISCERNIBLE 00:19:31] how." And all I wanted to do was, like, lay in my bed and watch. I don't know what I'm binging right now. It's probably the same thing I was binging the last time I was talking to you, which is probably-

MEGAN NEFF: Game of Thrones.

PATRICK CASALE: Again. And I just noticed it and I was just like, it just felt like everything times a million. And as a therapist that doesn't separate us from like knowing what's happening and being able to process things any differently when we have to show up as a helper, or as healer, or as a partner, or anything else. So, it's just like, you know, there are so many moments where I know a lot of my therapist friends who are either ADHD, autistic, both that are just struggling so badly in those moments, but then you have to figure out a way to almost overcompensate with your energy for those therapy sessions to then inevitably just fucking crash.

MEGAN NEFF: Yeah, yeah, yeah. So, I'm curious, how did you make it through that week? Or you were so burnt out?

PATRICK CASALE: I don't know. I mean, that was like, five days ago.

MEGAN NEFF: Okay, so you're in the week… you're still making [INDISCERNIBLE 00:20:38]. 

PATRICK CASALE: I think what was helpful, like, I was just in bed, and I think my wife who, you know, is definitely done her best to, like, get a sense of what's happening or going on for me when I'm not able to communicate it. And she knew something was wrong. And she was just like, "Anything I can do?" And I was like, "Nope." I just told her, like, everything right now is bothering me. Like, everything. And just being able to name that, I think, was helpful. 

I mean, and then I had my own therapy the next day, which was also helpful. And just, you know, I hate getting to that place where you're so depleted and burnt out, and you know, you're just so overwhelmed that I just don't like being short with people. I don't like being like, reactive in a way so that everyone knew, like, okay, you're about as far in as you can be in terms of depletion [INDISCERNIBLE 00:21:28] burn out.

But that doesn't mean that the job stops. And I think that's what's so hard for helping professionals, is like how to take care of yourself and still be able to show up for the clients that you're helping.

MEGAN NEFF: Yeah, yeah. It's so hard. And it's because, yeah, you can't put your work on toss, like, okay, I'm just going to cancel everything. I guess you could, and it's good to remember you can do that. You could be like-

PATRICK CASALE: You can do that.

MEGAN NEFF: I'm going to cancel clients for a week. 


MEGAN NEFF: In my mind, I forget that. I get so rigid in my thinking around that, that I forget it's okay to cancel sessions. Yeah, I wrote an article on this recently. And it's something I've been thinking about is, like, how it's shifted from me being an identity-based therapist or having an identity-based practice. And by identity-based, I mean having some form of marginalized identity in public about it, and then, kind of marketing or advertising your services around that because what it means is you're working with other people with that shared identity, and how that intersects complexity with this idea of burnout. 

In some ways, you know, my client load is pretty much all neurodivergent at this point, specifically, ADHD and autistic. And at this point, I'm only taking on autistic clients because it's so much easier to have neurodivergent conversations than to be masking as a therapist, which is what I've done for most of my career is mask while doing therapy. 

Oh my gosh, train of thought, Oh, okay, I remember. So, there's so many benefits of being an identity-based practitioner, but I think it also makes the burnout so much more intense and the moral injury more intense. 

So, I'm constantly saying no to people. And I don't have very many people to refer them to. And so, it's like, these are my people I'm saying no to, and I think that makes the burnout even more intense. And my client load keeps creeping up. I'm like, I'm going to max it at 10. And now I've got like 22 people because I keep taking on one more, like, once I hear the story. So, yes. I think that adds a added layer of complexity when you share identities with your clientele.

PATRICK CASALE: Yeah, I was just laughing because I so relate to the, like, you know, I only have a handful of spots, but then this person's story makes me realize I should have one more spot, yeah.

MEGAN NEFF: Right, it's so bad, yeah. Well, and so see if I read the email when I'm in my ADHD impulsivity, I'm like, "Sure, I'll let you in." But then my autistic self has to do the work of keeping up with it. That's where I really notice ADHD and autism conflicting for me is my ADHD part over commits, like, all over the place, and then, I feel like it's on my autistic self to, like, do all the work.

PATRICK CASALE: I am so glad you just named that because that's such a great transition and segue point to talk about, like, when one part takes up more space, which for all of us, you know, one of those parts is going to take up the majority of the room for the most part. You're right, like, the ADHD part of me is all excited, and it has this frenetic, like, energy, and like can be a bit impulsive in decision making. And then, the autistic part is like, I've got to clean this mess up that you may be just created because you've said you were going to say no to all of these things going forward and you did not? And how can you possibly show up, not just for your clients, but for yourself and for anything else in your life if you are just so depleted that you can't create and restore energy fast enough to keep up with it?

MEGAN NEFF: Yeah, when you figure that out can you let me know?

PATRICK CASALE: I was hoping and pausing that you're going to have the magic answer.

MEGAN NEFF: Yes, yes.

PATRICK CASALE: And, you know, I think that for those of us who our autism is primary, ADHD can be fun, and it can cause a hell of a lot of chaos too in my life.

MEGAN NEFF: Yes, yes, absolutely, absolutely, yeah. And I mean, for you, can you tell, like I can kind of, and I do, I like parts work as I think you do, too. It feels like a different energy. And I can tell when I'm in my kind of creative, impulsive, energetic energy. And I can tell like, this feels like a really good idea. But like next week, when you're, you know, maintaining a Patreon, and Instagram, and your clients, and assessments, you're going to hate the idea of starting the YouTube channel or whatever it is. But in the moment, like, it's like, no, this is great. I'll be fine.

PATRICK CASALE: Yeah, you know, the struggle, I think, is that those moments feel pretty damn good because the alternative is like, feeling more flat, and low, and where everything does feel a bit painful in some way or another. And it's nice when like… and that's why ADHD and bipolar disorder get misdiagnosed so often, as you talk about on Misdiagnosis Mondays, like, it makes so much sense why someone may present when their ADHD is kind of steering the ship and then get diagnosed with a manic episode.

MEGAN NEFF: Oh, absolutely. Yeah, yeah. 

PATRICK CASALE: And then, just trying to balance things out. And, you know, thankfully, I mean, I do love parts work, I've been doing a lot of it, and in my own therapy. And it's been very helpful right now because my therapist is like, "All right, I hear this part of you that's like, 'I want to create this retreat next year' and I just want you to pay attention to the part of you that's like, 'Please do not do anything else.' Like, please try to at least acknowledge that part. And let it know that you see it because otherwise, here we go again." 

And I'm definitely getting better at saying no to things. Like, I've actually taken pride in that recently being like, everyone reaching out to me for coaching, for podcasts, for anything at all right now, I'm like, "Not until 2023 and I don't have a firm date on that with surgery looming." So, like, it's actually kind of a reprieve in a way to say like, I cannot do these things. Like, there is no chance this can happen. But that doesn't mean that when that idea creeps up you don't want to follow it. And like you don't want to take advantage and harness the energy that is showing up for you when you're so used to just being pretty low energy in general.

MEGAN NEFF: I think that's part of it, I know for me, and I feel like I see this for other folks as well. But I'll speak from my experience, is I don't necessarily want to sit with that part of me, the part of me that's like, "No, say no to my limits." Because that's the part of me that is incredibly limited. 

You know, last time I was on, we talked about the importance of holding space for grief. That's the part of me I grieve, the part that gets so exhausted so easily and who has incredible sensory limits and very real energy limits. I don't really want to spend a lot of time with that part of me, and so, the, you know, again, in psychoanalytic terms, you talked about the manic defense of, in this case, I guess, the ADHD defense, the energetic, impulsive defense of like, no, that's not who I am. I'm the person who is creative and goes and starts five different projects because I think it's so painful to acknowledge how integral that very fatigued, tired, part of me is to who I am.

PATRICK CASALE: I couldn't say it better myself. I think there is a major grief process there with recognizing, and seeing, and acknowledging that that part is very real and takes up a lot of space, maybe it takes up the majority of the space. And I think that for me, that is why I typically do pursue these, like, sparks of creative energy when I have them because I know that what lies on the other side of that is just that utter depletion. 

And, you know, for those of you listening who identify, or can relate, or even who just experience pretty major depression. I mean, it's not a fun place to be. It's exhausting. And it sucks to think like, "I'm tired all the time. How do you break out of it?" So, then when it does happen for that two- or three-day period, or whatever the case may be, it makes complete fucking sense to me why you would be like, "Yes, finally. Like, I needed this." You know?

And I certainly try to see the duality in that and just the realization that that is my process because I think for so long, I tried so hard to figure out, like, how to put limitations on myself in terms of like, say no, say no, say no, rest, rest, rest. But like, in reality, if you're tired all the time, and you're resting, resting, resting, then what is wrong with also pursuing the parts of you that, like, really excite you and light you up too?

MEGAN NEFF: Yeah, yeah. I like that way of thinking about it. Yeah, yeah.

PATRICK CASALE: You know, I still struggle with it, for sure. I think I've gotten better at it. And I told my therapist just the other day, like, I noticed, like, if I start to pay attention, like cyclically, and to seasons, okay, as the fall approaches, I love the fall, but I do notice this major, major energy dip. 

And you know, I know you're in California, so maybe you're not experiencing the fall like we are, but you know, it'll be cold here, and it'll be dark. And it is a nice time to kind of be like, all right, shutting everything down. So, I think I've made sense of like, my process of being really creative from like, I don't know, March to August, and then, the rest of the year is just kind of slowly, like, just coming back to a place where you're like, I can't say yes to anything else. And instead of trying to change that, or set parameters on myself, or like, hey, I'm going to agree to do these things. I'd rather just be like, this is just my fucking life. Like, this is my process and I'm going to be okay with that.

MEGAN NEFF: Yeah, yeah. So, I actually wish I was in California. I'm in Oregon, and we have very long gray winters. And I experience the same thing of like, okay, spring and summer, I can count on having energy. I tend to get a lot of projects on, I tend to overcommit during spring and summer. And then, you have fall and winter, like, fatigue is just so, so intense.

PATRICK CASALE: Yep. Do you start to notice it like starting to creep in. Like, I noticed that this year, and I've been paying more attention to my energy, in general, this year, but like, as soon as August 1st hit, I noticed there was like this shift for me where I'm like, "Oh."

August is my first month. Like, I like August, I like September, I like October, but I also felt myself like realizing like, okay, my energy's dipping. Like, it's time to start paying attention to what you're saying yes and no to, not in terms of like creative energy, but obligations of things that you may not necessarily want to do. Like, there's no reason to do the other networking call or the extra Zoom webinar or whatever, at this point in time because if you want to, like, be functional throughout the next couple of months, you really have to basically start to be really intentional about what you're doing.

MEGAN NEFF: Yeah, yeah, absolutely. To answer your question, I don't think I notice it that early for me. For me, it comes on more when that like it's very connected to light. So, once the days start getting shorter, so I think kind of mid-October, November. 

Let me ask you, I'm curious. So, this year has been a big experiment. It's my first year of my private practice. And I'm still figuring things out. But I feel like in general, I have created ways where, so I've got kind of inputs and energy outputs. And I protect my time to create content, to create digital workbooks because that, again, if I have too much on my plate everything is an energy zap, but when I have a kind of decent amount on my plate, those actually restore my energy to like, sit out on my porch in the sun and to be diving into a special interest. I'm curious, do you find that too where there's part of your work that actually are energy inputs for you?

MEGAN NEFF: I'm so glad you asked that. Actually, a great question. And yeah, absolutely. Like, there are things that I do that are very energizing. But like you said, when I have too much on my plate, when I'm like answering these things, and all of these places, and working on things that aren't really my jam, but they're a part of my day-to-day, that's when I start to notice like, everything gets magnified and intensified in those situations.

There are things that I absolutely love doing where I don't even look at it as work a lot of the time. So, I think that a lot of people maybe struggle to conceptualize that. I know, you and I talked a little bit about, like, the difference between special interests and hyper fixations, and also, like hustle culture that can get so [PH 00:35:51] misidentified a lot of the time, especially, for people who are like parts of my day-to-day or work or career are very energizing. I think I've been with like this look of like, that's just workaholism talking. And I just knew for sure that is not the case.

MEGAN NEFF: That just feeled like such a simple narrative. So, just, it's workaholism. It's like, okay, no, like, what's behind it? What's the function? What's the person getting out of it?

PATRICK CASALE: Yeah, absolutely. But I love that question because that's definitely a part of it for me. Like, I was writing before. And I noticed, like, when I'm really feeling good, like, I'm writing a lot and I'm being really creative. And I was like, "Oh, I could probably like really create a bunch of content right now, and this feels really good, this feels really energizing." 

Now, if you turn that and flip it around, and you say, "Oh, you're getting all these calls in your group practice, and your office manager has COVID, and is sick, and is out, and you have to answer them, that is not energizing for me. Like, that is like, look at the message, look at the message, look at my phone, and just be like, "All right, so who wants to a buy group practice? Anyone out there looking?" 

So, you know, I think, special interest, having things that we really enjoy doing, I think is so crucial as well, and not just for autistic and ADHD people but like, everybody needs this. And we need to have these things that we really enjoy doing. But especially, for those of us who, you know, special interests are really a big part of our world. I mean, I need those things in my life. And I need those things because they make me not only feel good, but they energize me as well.

MEGAN NEFF: Yeah, yeah, yeah. That's my kind of ideal equation I'm working toward where I've got kind of equal amounts of energy input and energy output and can make a career out of it. I think I have to learn how to say no before I do that, but that is the goal I'm working towards.

PATRICK CASALE: [CROSSTALK 00:37:50]. Oh, go ahead, sorry. 

MEGAN NEFF: Oh, no, go ahead. 

PATRICK CASALE: The next time that I talk with you, whether it's on here, or on Instagram, I'm going to say, "Are you still at 22?" And if you say to me, "Oh, I'm actually at 33."

MEGAN NEFF: 25. Oh, no. Yeah. And I partly for, like, ethical reasons, I know I just can't do that. I become a less effective therapist when I've seen that many. And so, like, I'm at a point where I'm like, okay, ethically, I can't take on more people because I know it'll be less effective for everyone on my caseload, yeah.

PATRICK CASALE: Absolutely. 


PATRICK CASALE: I agree, 100%. What were you going to say, if you remember what you were going to say?

MEGAN NEFF: Oh, it was just, when you were talking about kind of the drains, one thing I noticed it, like the pings and the pongs, like the, you know, responding to messages, and that stood out to me because I feel like that is the number one drain. I don't know why I did this to myself, but I have five different email accounts I track. And then, you know, I post on Instagram, I post on Facebook, I'm starting to get into Pinterest. And it almost induces panic, how many, like, pings come at me. 

And I both feel proud of myself, and I feel negligent about this. So, my Instagram, I had several posts go viral in the last six weeks, so it just, like, more than doubled in six weeks, and it's just gotten very active. So, I stopped reading comments. And that on one hand, it's like okay, if I'm a content creator, I like have this responsibility to read comments and respond. But there's no way I'd be a content creator if I was doing that. And so that is one accommodation I've given myself is like I'm just not going to do it, partly, because of rejection sensitivity. And even if there's 100 positive comments, one negative comment will hijack my nervous system and then I'll resent that I'm so like, freaking fragile. But yes, the pings and the pongs. If I could just erase all of those, I think my nervous system and my body would feel so different.

PATRICK CASALE: Yeah, my therapist would laugh because we had a whole conversation about this the other day about being responsive to the pings and the pongs in all the different platforms that people message me on, whether it's like Voxer, Facebook, Instagram, all the things and there is that part of me that like, is overly responsive, and I'm trying so hard not to be, then there's the part who like, hates all red notifications on my phone, so I have to clear them and then, I feel bad I [INDISCERNIBLE 00:40:35] them. 

I had a TikTok video go viral back in May and it hit like upwards of a million. And the comments, like, responding to the fucking comments for days consumed my life for like three days, and I have not opened that app since that time. Like, because I got so inundated with like, I have to respond to everybody, I have to like, and then, like you said, negative comments, oh my God, then that hits my ego, and then, like my rejection sensitivity kicks in. And then, I want to smash my phone with a sledgehammer, and then, like, I seriously have not opened the app since that day and I won't. 

And my social media person's like, "Why aren't you going back on TikTok? Like, you were building an audience." I'm like, "Nope, don't want it, don't care, can't do it." Because like, I know I just have to have some limitations and accountability to myself because it could be endless. 

And I mean, you make really incredible content, and you've got a huge following, which is only going to increase and I know the anxiety that that can also bring. Like, it's a double-edged sword. It's wonderful, it's fantastic, and it's exhausting too. 

Like, even running my Facebook group, we're almost at 7000 people in that group. And the bigger the group, the more you have to moderate, the more you pay attention, the more you have to make sure you aren't doing, like, stupid shit. And it's just like, all right, I love my members. It's also exhausting. And just trying to remember that, like, I can't be involved in it 24/7. It just can't happen.

MEGAN NEFF: Yeah. I also wonder how much that has to do. It's interesting, I've always thought of it as kind of an ADHD thing of like, my inbox is just atrocious. But for the first time, I'm also thinking about it from an autism frame of when that takes up a lot of our day it's unexpected demands that come at us. And I'm pretty like, I wouldn't say I'm not PDA, but I have a strong demand avoidance. I don't like being told what to do. And so, all of these, whether they're coming out as from Instagram, or Facebook, or email, they're all incoming demands. And even if it's a comment, like it's small, but that's hundreds and hundreds of demands that weren't necessarily budgeted into the day that are unexpected shifts. And so, I'm kind of thinking out loud here, but it's giving me more compassion for myself of why it's so hard because this is not what I had planned for the day. I had planned an hour of deep thinking not like responding to comments time, and now an hour's gone, and that wasn't my plan for the day.


MEGAN NEFF: That's stressful.

PATRICK CASALE: Absolutely. And then throwing time blindness into the equation, and then you know, you're spending your day doing something you didn't want to be doing only not intending, and you know, I try really hard to start my day without like picking my phone up immediately and looking at it because I know already, like, there are going to be all these messages to respond to. So, trying to start my day, like, doing something different, going to get coffee, going to, you know, just do anything that isn't phone related before diving in because otherwise, I will be responding to things at like 7:38 am, as soon as I get up till the moment I put my phone away to go to sleep. 

So, I do think that's a really good point, Megan. I appreciate you naming that because I think it is those little demands that, like, in little quantities don't seem like much, but when you start to add them on top of each other, I mean, it can take hours of your life and of your day of the week. So, like, I think we can use this episode not just for everyone else listening who identifies with any of what we're talking about, but for ourselves to hold each other accountable because, you know, you have a lot to offer the world, and you have a lot of great information coming out and it's only possible if you have the energy to continue to do it.

MEGAN NEFF: And, likewise to you. And you know, I think all neurodivergent content creators I see… and I really appreciate the conversations around burnout and boundaries because it is interesting. In some way I feel like being a content creator is more draining, that the people involved in being a content creator is more draining than being a therapist. 


MEGAN NEFF: I think. And so, there has to be boundaries if it's going to be sustainable. And it's really, really hard, I think to put up those boundaries because of all the things we've talked about. I think the desire to respond, especially, to our community of people, rejection sensitivity. Yeah, it feels really painful that I can't respond to all the DMs, you know, especially, I think most of the unanswered DMs are like, "How do I get an assessment?" Which I just frankly, I can't answer that because it changes by country, it changes by state, it changes by insurance.

And that's part of the experience, right? Opening the app and seeing all these needs that I cannot address. And that's part of the moral injury, I would say of, again, being an identity-based creator or therapist.

PATRICK CASALE: Absolutely. Yeah, absolutely. I think you're 100% right. And then, there can be a lot of guilt and shame that comes up around not being able to respond, or help, or navigate this one. I will say, that was another big reason I stopped talking about it on TikTok because I was just getting people from all over. And I know you do already with the content you create, just people from everywhere asking me, "Can you be my therapist? Can you connect me to a therapist? Can we connect?" And I'm like, I want to, but I can't do this. Like, I cannot respond to all these people. 

So, for those of you listening, you know, whether you're a therapist or entrepreneur, or, you know, have similar experiences, just know that it is okay for you to take a step back and set some boundaries and limitations for yourself to preserve your energy as well because we all know that we cannot take care of other people if we cannot take care of ourselves. And I think that's just really paramount in this conversation right now for both of us as we're both exhausted and just talked for 55 minutes. So, I want to give us both like congratulations on that. And for everyone listening, I appreciate it very much. 

And Megan, I just want to say that I really, really, really appreciate becoming friends this year, and colleagues, and just being connected. And I just really love what you're doing for the autistic and neurodivergent world.

MEGAN NEFF: Thank you so much. I think you're, all right, I guess, I shouldn't say things like favorites, but you're one of my favorite things to come out of Instagram. I really have enjoyed our conversations both on the podcast and off. It's just felt really, well, I would say an energy input to be connected with you. But thank you.

PATRICK CASALE: The feeling is mutual for sure. So, thank you too. Do you want to tell anyone where to find you so you can further increase your followers on Instagram?

MEGAN NEFF: Well, I will tell them they can find me at and on Instagram. And I'm so sorry, but I will probably not be seeing your comment or responding to it. I am a little better with DMs but I don't respond to any sort of medical request.

PATRICK CASALE: Love it. Good boundaries and wonderful information coming out that will be in the show notes as well. And again, just thank you for making the time and I hope that everything starts to settle down out in Oregon as well. 

MEGAN NEFF: Thank you. Thank you so much.

PATRICK CASALE: To everyone listening to the All Things Private Practice Podcast, there are new episodes coming out every Sunday morning on all major platforms. Like, download, subscribe, and share. If you want to find out more of what I have to offer, go to for upcoming entrepreneurial retreats, private practice, podcast episodes, coaching programs, and more. You can also join the All Things Private Practice Facebook group. Doubt yourself, do it anyway. I'll see you next week. Thanks, Megan.


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