Autism is not a mental health condition - however autistic people are more likely to experience poor mental health than those without autism. In the past, mental health symptoms were likely to have been attributed to the person having autism, rather than to a co-occurring mental health difficulty, however it is now understood that mental health conditions often occur alongside autism. Understanding of mental health difficulties in autistic people is continuing to develop, and this understanding is important to guide appropriate treatment and support.
Psychological therapies are a range of interventions based on psychological concepts and theory, designed to support individuals to understand their emotions, thinking, behaviour and interpersonal relationships, in order to relieve emotional distress and improve functioning.
Cognitive Behavioural Therapy (CBT) is an evidence-based intervention used to treat anxiety, depression, and other mental health conditions. CBT is the most widely researched psychotherapy with proven efficacy in the treatment of mental health disorders in both children and adults. CBT is a first line treatment for many disorders and is recommended in NICE and SIGN clinical guidelines.
The precise delivery of CBT will vary – for example, techniques for treating children will use different language, pictures or visuals and practice examples, compared to treatment for adults. Parents and carers can also support the delivery of CBT with children. Similarly, adaptations are made to CBT for people with learning disabilities. CBT can also be delivered in a group or individual format, and in a computerised CBT intervention.
Other evidence-based interventions for mental health conditions include Interpersonal Psychotherapy (IPT), Behavioural Activation (BA) for depression and Family Interventions for schizophrenia. All psychological interventions involve developing a positive therapeutic relationship and working collaboratively on identified goals.
SIGN guideline 145: Assessment, Diagnosis and Interventions for ASD highlights there is insufficient evidence to recommend any specific psychological intervention for people with ASD. The guideline recommends that a diagnosis of ASD should not prevent anyone from accessing psychological interventions and that autistic individuals should be offered treatments in line with recommended clinical guidelines for the presenting problem. The guideline also recommends that adaptations to CBT should be considered, such as using clear concrete language, avoiding use of metaphors and increasing use of written and visual information.
An online survey highlighted autistic individuals’ experiences of counselling and talking therapies (Hallett & Kerr, 2020). Factors identified as important are
Clear information about the approach or intervention; warmth and acceptance from the practitioner to build a trusting therapeutic relationship
Accommodations to physical space to support sensory/environmental needs
Practitioners to understand and believe autistic individuals’ experiences of distress, and recognise the difficulties with describing and regulating emotions
Importance of building a collaborative relationship to empower the individual, and being understanding, flexible and creative
For practitioners to have some knowledge of autism along with a willingness to learn and be open to the experience of the individual.
Decisions on appropriate psychological interventions therefore involve
Identifying/assessing the presenting problem with the individual
Using clinical guidelines to identify evidence based interventions for the presenting problem
Assessing the individual’s skills and abilities to engage in identified psychological interventions
Considering access to appropriately trained clinicians in the identified interventions
Collaborating with the individual to decide on intervention (including giving clear information and building a collaborative therapeutic relationship)
It is increasingly recognised that for autistic individuals, mental health presentations and underlying mechanisms may differ to those affecting non-autistic people and that further research is needed. While there is limited research on the efficacy of adapted psychological interventions for autistic people, systematic reviews of studies suggest CBT and mindfulness are effective treatments for anxiety in autistic people (e.g. White et al 2018; Benevides et al; 2020).
Psychological intervention is collaborative and dependent on the development of a therapeutic relationship. Psychological intervention adapted for autistic people should explore individual goals carefully and work with the person to understand their experiences. This ensures neurodevelopmental differences are accepted, and the focus is on difficulties which are causing distress and impacting on functioning and quality of life.
NES provides resouces for Behavioural Activation for depression across the lifespan. This includes an adapted approach for people with intellectual disabilities, Beat It.
Let's Introduce Anxiety Management (LIAM) is currently offered across Scotland to children and young people with mild to moderate anxiety. This includes children and young people with neurodiversity.
With increased risk for autistic people, promotion of good mental health and prevention of suicide is important. A range of mental health improvement and suicide prevention resources are available.
Supporting autistic children and young people through crisis is a resource developed by Autistica which highlights the mental health challenges and suicidality experienced by many autistic people, and makes recommendations for adapting practice and service.
The NES Autism and Neurodiversity Team will continue to explore best practice in adapting interventions for co-occurring mental health conditions. For information on current training plans, please contact Psychology@nes.scot.nhs.uk