Adapting Drug and Alcohol Therapies for Autistic Adults

Abstract

Background:

Autistic people may be at a higher risk of drug and alcohol misuse than the general population. Autistic people, however, are under-represented within drug and alcohol support services. This is the first survey of drug and alcohol therapists' perceptions of current service provision for autistic clients and recommendations for reasonable adjustments that therapists can make to enhance successful outcomes.

Methods:

We conducted an online survey of 122 drug and alcohol therapists, exploring therapists' demographics, training and experience with autistic clients, approaches and adaptations used with autistic clients, and therapists' confidence with autistic clients. Within two focus groups, 11 members of the autistic and broader autism (e.g., family members, professionals) communities reflected on the reasonable adjustments reported by therapists.

Results:

Most therapists had autistic clients and most therapists had received no autism-specific training. Alcohol misuse was the most common presenting issue, and most therapists reported that treatment outcomes were less favorable for autistic clients than for other groups. Therapists perceived that barriers to successful outcomes were (1) a lack of autism-specific training, (2) a need to adapt therapy for autistic clients, and (3) a lack of shared perspective between the therapist and the autistic client. Previous research has identified a range of reasonable adaptations and, when asked, therapists were moderately confident in their ability to deliver these. Members of the autistic and broader autism communities coproduced guidance detailing how therapists can best adapt their practice for autistic clients including how to structure sessions and the language to use within sessions.

Conclusion:

This study highlights a need for practical and theoretical training for drug and alcohol therapists to support successful adaptation to current service provision for autistic clients and to develop a shared perspective on the desired aims and outcomes of the therapeutic process.

Community brief

Why was this study done?

Autistic adults may be at greater risk for consuming drugs and alcohol to harmful levels compared with nonautistic adults. Autistic adults seeking support for drug and alcohol use report that treatment programs for reducing drug and alcohol use do not meet their needs.

What was the purpose of this study?

This study aimed to look at the skills, experience, and confidence of drug and alcohol therapists in working with autistic adults and what adaptions they are making to support autistic service users.

What did the researchers do?

Through an online questionnaire, the researchers asked 122 drug and alcohol therapists about their experiences with autistic clients (such as what issues they presented with), their autism training, and any perceived barriers or adaptations made to their service. Researchers also asked the therapists how confident they were to work with autistic clients and how successful their treatment was when compared with other client groups. Through two focus groups, the researchers then asked members of the autistic and broader autism (e.g., family members, professionals) communities to reflect how the reasonable adaptions reported by the therapist could be most effective for the autistic community.

What were the results of the study?

Most therapists had autistic clients and most therapists had received no autism-specific training. Alcohol was the most reported misused substance that therapists working with autistic adults encountered. Most therapists also reported that treatment outcomes were less favorable for autistic clients than for other groups. Therapists identified lack of training as a barrier to providing support for autistic adults. Therapists suggested that a one-size-fits-all approach was not helpful for this group and most were moderately confident that they would be able to deliver adapted therapy to autistic clients. Members of the autistic and broader autism communities developed guidance for therapists to implement effective adaptations for autistic clients.

What do these findings add to what was already known?

This was the first survey of drug and alcohol therapists regarding their service provision for autistic clients. The findings highlight the need for therapists to be trained in how to adapt support and treatment to meet the individual needs of autistic clients.

What are potential weaknesses in the study?

One limitation of this study is the convenience sample. This may limit how we can generalize the findings. By asking specifically about autistic clients, we may have biased responses from therapists who have worked with autistic adults.

How will these findings help autistic adults now or in the future?

The findings from this study highlight that treatment programs for drug and alcohol misuse do not consider the needs of autistic adults. However, they also suggest that various approaches and adaptions can be made to support autistic clients. In addition to supporting adaptions made by therapists, the guidance developed could be a useful framework for autistic clients to discuss their session-support needs with therapists. Future research should look at the effectiveness of these adaptions in improving treatment outcomes for autistic clients.

Introduction

There is limited literature available on the co-occurrence of autism and substance use disorder (SUD).^1–4 Helles et al.⁵ report 18% of autistic adults have alcohol-related problems, compared with 12% for drug-related problems.^6,7 However, although research reports that alcohol-related problems are 4 times more likely in autistic people than in nonautistic people, drug-related problems are 8.5 times more likely,^8,9 and combined rates of these problems are much lower for this group (2%–4%).^10–13 Systematic reviews of the co-occurrence of autism and SUD have identified huge variability, with figures ranging from around 1% to 36%, making it impossible to establish a reliable prevalence figure.^1,4

These reviews found that few studies reported formal diagnostic criteria for SUD, and definitions of SUD ranged from “having experienced trouble with alcohol or drugs” to “current substance addiction.” Research also suggests that the co-occurrence rates may be higher in adulthood than in adolescence.^2,13 The only consistent finding is the reported lack of knowledge among professionals on how to treat this group of service users.¹⁴

In many cultures, alcohol is legal and other drugs related to SUD are illegal, and a tendency toward literal interpretation of rules may make autistic people less likely to experiment with illegal substances.¹⁵ Bowri et al.¹⁶ report that 15.2% of autistic adults drink alcohol to “hazardous” levels and previous research suggests that there is a greater risk for autistic adults to be more likely to consume alcohol to alleviate the anxiety they experience in association with their social difficulties.^17–19 Once alcohol use is initiated, progression to an alcohol use disorder can be accelerated in autistic adults.^20,21 However, prevalence rates of “at risk drinking” are lower in young autistic adults.²²

Autistic adults report social facilitation and self-medication as common themes in substance use and, in addition, autistic adults report that treatment programs for misuse do not take account of autistic characteristics.^23,24 Consistent with this, although autistic young people or those with intellectual disability are over-represented in many public services such as mental health, educational services for youth with serious emotional disturbance, and child welfare, they are under-represented in juvenile justice and alcohol and drug services.²⁵ A recent survey of over 500 adults reported that if members of the autistic community perceived problematic issues with their alcohol drinking, 45% would not seek help and 49% would access the internet for information.²³

A case study of an autistic adult with intellectual disability suggested that conventional approaches to treating alcohol dependence may not be entirely appropriate for this group and that reasonable adjustments need to be considered.^3,26,27 This case study is significant as the 1995 Disability Discrimination Act (UK) requires public services to make reasonable adjustments in order for people with a range of disabilities to access their services on an equitable basis.²⁶

In a survey of the research priorities of the autistic community, the number one research priority identified was “How can public services best meet the needs of autistic people?” (61%).²⁸ This area, however, receives one of the smallest allocations of research funding in the United Kingdom, and there is no evidence for which (if any) reasonable adjustments work for autistic service users within drug and alcohol services.

One methodology to develop an evidence base for useful reasonable adaptions is to identify the reasonable adjustments that therapists are already making to traditional service provision. Cooper et al.²⁹ conducted a survey of 50 cognitive behavioral therapy (CBT) therapists to identify therapist skills, experience, and confidence in working psychologically with autistic people, to highlight gaps and needs, as well as strengths in terms of therapist skills when working with this group.

This study applies Cooper et al.'s methodology to explore the skills, experience, and confidence of drug and alcohol service providers, and what adaptions they are making for autistic service users. As an additional step, we subsequently asked members of the autistic and broader autism communities to reflect on the adaptations made by therapists. We conducted two focus groups with the goal to develop accessible guidelines for therapists working with autistic clients.

Methods

The psychology research ethics committee at the University of Bath provided ethical approval. Participants did not receive any reimbursement.

Survey participants

We required participants to be working in drug and alcohol services in the United Kingdom and aged 18 years or over. We placed recruitment invitations in the Drink and Drug News magazine and the changegrowlive.org webpages, as well as through the Network Autism pages for professionals, part of the National Autistic Society webpages (United Kingdom). In total, 169 drug and alcohol therapists accessed an online survey. Two did not provide consent for their data to be used and 45 did not respond to any questions in the survey, leaving 122 participants (72%). All participants reported working in the United Kingdom.

Survey measures

The study design was a cross-sectional online survey. We adapted the online survey from Cooper et al.,²⁹ adjusting CBT wording to be appropriate for drug and alcohol service provision, and it took around 10 minutes to complete on average. This assessed therapists' demographics, training and experience, adaptations made for autistic service users, and therapist confidence. The Results section shows the wording of the questionnaire. One question was a free text question concerning perceived barriers to treating autistic adults.

As with Cooper et al., the survey finished with the 14-item therapist confidence scale (TCS), adapted to make it appropriate for autistic clients specifically. Dagnan et al.³⁰ developed the Therapist Confidence Scale for Intellectual Disabilities (TCS-ID) and Cooper et al.'s version replaced “Intellectual Disability” with “Autism.” We used the Cooper et al. version of the TCS in this study. Responses could range from 1 (not at all confident) to 5 (totally confident) for each item. Mean scores could, therefore, range from 1 to 5. Cooper et al.²⁹ reported a mean of 2.96 (SD = 0.78) and a Cronbach's alpha of 0.92. In this study, the adapted TCS-ID had a Cronbach's alpha of 0.95.

Survey data analysis

The number and percentage of responses for each question are reported hereunder, highest through to lowest. Not all participants answered all of the questions, and the number of participants, therefore, vary between the analyses given. (n = xx) indicates the number of participants who responded to each question. For the free text question, we subjected responses to content analysis, coded them into categories, generated frequency counts for each category, and identified sample quotes. A second independent reviewer confirmed the codes (Cooper et al.²⁹). There was 91% agreement between the two judges. The six responses where there was a disagreement typically referred to two categories, and we resolved these through discussion, resulting in 100% agreement.

Focus groups

The Cooper et al. methodology concludes by asking respondents about any adaptations they make in treatment/support techniques when working with autistic people, which are reported in Table 5. To explore the autistic and broader autism communities' perceptions of these adaptations, we took the adaptations in Table 5 to the National Autism Wales Conference focused on promoting autistic well-being. We ran two focus groups, totaling 12 people, 1 of whom did not consent for their data to be used, leaving 11 people from the autistic and broader autism communities (autistic people, n = 3; families/carers/advocates, n = 4; professionals, n = 4) who discussed the adaptations in Table 5.

The focus group participants discussed the adaptations with a view to developing accessible guidelines for therapists working with autistic clients. We compiled the proposed guidelines from the two focus groups and individually emailed the output to the members of the focus groups for further comment (after Zervogianni et al.³¹).

Results

Therapist demographics

Of the 122 therapists who participated, 75 (61%) worked in community drug and alcohol services, 10 (8%) worked in local authority social services, 8 (7%) worked in a hospital setting, 8 (7%) worked in outreach services, 5 (4%) worked in residential rehabilitation centers, and 16 (14%) worked in other services (e.g., housing, police). In total, 114 therapists (60%) worked with working age adults (18–65 years), 55 (29%) worked with older adults (65+ years), and 20 (11%) worked with young people (under 18 years).

On average, the number of years respondents had been working in drug and alcohol services was 11.04 (range from 1 to 40, SD = 7.86 years). The highest level of qualification obtained was 20 national vocational qualifications (NVQs) (16%), 35 diplomas (29%), 26 undergraduate degrees (15%), 19 postgraduates (16%), and 11 in others (e.g., nursing or in-house training) (9%). Nine people (11%) did not respond. NVQs and diplomas are typically work-related qualifications. NVQs are typically undertaken in the workplace and diplomas are typically undertaken through university/college while working.

Overall, those with an NVQ had a mean of 7 years working experience, those with a diploma or undergraduate degree had a mean of 11–12 years working experience, and those with a postdoctoral degree had a mean of 15 years working experience. However, the number of years working did not significantly differ by level of qualification, though there was a trend (Kruskal–Wallis (3) = 7.55, p = 0.056; n = 100).

Experience with autistic clients

We asked therapists about their experience with autistic clients and training. Table 1 highlights the number (and percentage) of responses (questions in the left-hand column). Table 1 highlights that 63 therapists reported no autism training and 55 reported some level of autism training. Those who had not received any autism training had worked for a mean of 12 years (SD = 8) and those who had received training had worked for a mean of 10 years (SD = 8). This difference was not statistically significant (t(116) = 1.58, p = 0.118). In addition, self-reporting of autism training did not significantly differ by level of highest education (F(3,99) = 0.95, p = 0.421).

Table 1.

Therapists' Experience with Autistic Clients

	Yes	No	Unknown
Would you know whether a new client had autism? (n = 117)	63 (54%)	17 (15%)	37 (32%)
Current experience of working with autistic clients?(n = 116)	54 (47%)	47 (41%)	15 (13%)
Previous experience working with autistic clients?(n = 102)	95 (93%)	7 (7%)
	None	Theoretical information	Practical training	Both theoretical and practical
Received any autism-specific knowledge and/or skills?(n = 118)	63 (53%)	32 (27%)	8 (7%)	15 (13%)
	Referral paperwork	Own judgment/experience	Ask client if notice traits	Service has protocol
How would you know whether a client was autistic?(n = 63^a)	46 (34%)	35 (26%)	31 (23%)	12 (9%)

n = number or respondents. % refers to the proportion of responses to the question. There was only one response allowed per question, except where indicated.

More than 1 response could be provided to this question, 133 responses were provided in total. “Other: please state” was also an option (N = 11, 8%).

Therapists with experience of working with autistic clients also reported a modal response of currently working with 1–2 autistic clients (range from 1 to 30) and having worked with 2 autistic clients in the past (range 1–100) (Table 1). Taking current and past clients together, half of therapists had worked with four or less autistic clients (and half with five or more autistic clients). Therapists who had been working longer (r(94) = 0.21, p = 0.039) and those who had autism-specific training (t(65.22) = 2.45, p = 0.017, equal variances not assumed) reported a higher total number of autistic clients (current and past combined).

Highest level of education did not significantly relate to number of autistic clients (F(3,82) = 0.90, p = 0.446). Table 1 also highlights that 54% of therapists would formally know the diagnostic status of autistic clients, through referral paperwork or service protocols. Thirty-two percent of therapists reported that they would not formally know their clients' diagnostic status and would use personal experience or judgment or would ask the client about autistic traits. Some therapists also reported other ways of knowing a service user was autistic, mainly along the lines of “Generally the client would disclose.”

Fifteen percent of therapists reported they would not know (formally or informally) if a client were autistic. We then asked therapists what issues clients typically presented with currently and in the past. Table 2 highlights that alcohol misuse was the largest presenting issue (current and past). The only other presenting substance misuse listed more than once was cannabis (n = 4, that is 3% of current presenting issues).

Table 2.

Number and Proportion (%) of Presenting Issues for Autistic Service Users

	Alcohol misuse	Illicit drugs	Prescription drugs	Steroids	Other
Current(n = 54^a)	50 (39%)	39 (30%)	22 (17%)	6 (5%)	12 (9%)
Past(n = 77^a)	71 (39%)	48 (26%)	30 (16%)	13 (7%)	22 (12%)

more than one response could be provided to this question.

n = number of respondents.

We then asked therapists how they viewed the outcomes for autistic clients compared with other service users they had worked with. Table 3 highlights that the outcomes were generally considered to be worse for autistic clients than for other service users. In addition, 13 of the therapists (14%) did not know how the treatment outcomes of autistic clients compared with those of other service users.

Table 3.

Perceived Relative Outcomes for Autistic Service Users

	Very much worse outcomes	Less favorable outcomes	The same outcomes	Better outcomes	Very much better outcomes
Outcomes(n = 79)	9 (10%)	45 (49%)	19 (21%)	3 (3%)	3 (3%)

n = number of respondents.

Approaches and adaptations used with autistic clients

We asked therapists to rate how helpful they thought a series of treatment approaches were if they had been used with an autistic client (with 0 being least helpful and 10 being most helpful). As therapists only rated the approaches they had used, different groups of therapists rated different approaches. Table 4 highlights the mean scores. Therapists found eclectic approaches most helpful and psychodynamic approaches least helpful.

Table 4.

Mean Helpfulness of Differing Therapeutic Approaches

Eclectic (n = 22)	6.71 (range = 0–10, SD = 2.30)
Family therapy (n = 16)	6.37 (range = 0–10, SD = 2.42)
Cognitive behavioral approaches (n = 35) (including behavioral therapies)	6.18 (range = 2–10, SD = 2.35)
Systemic approaches (n = 22)	6.09 (range = 0–10, SD = 2.38)
Psychodynamic (n = 16)	3.94 (range = 0–10, SD = 2.74)
Other (n = 12) (e.g., motivational interviewing, brief interventions)	4.73 (range = 0–10, SD = 3.75)

n = the number of therapists who rated the helpfulness of the approach. Only therapists who used each approach rated it for helpfulness.

We asked therapists whether they had encountered any particular issues or challenges working with autistic clients. Sixty-seven respondents entered free text that we clustered under three headings through a content analysis [two respondents (3%) also answered “no”]. A second independent rater confirmed this with agreement of 91% and we resolved differences through discussion (Methods section). The responses came under three categories: 1.

Lack of adaptation: 33/67 (49%)

This theme covered therapists' challenges with the flexibility that was required for therapy sessions (such as length and frequency) as well as with communication style and the development of relationships. Therapists felt that a lack of adaptation to meet the individual needs of autistic clients resulted in disengagement with the service. They mentioned difficulties with group work as a specific issue. Sample quotes:

Communication can be more difficult as the client can be less expressive and less responsive, therefore timescales are lengthened for treatment and also care plans need to me [sic] be modified to reflect that.

We commission lots of substance misuse rehabs. people with autism or any other learning difficulties struggle to do well in this environment as group work is not often the best method of learning. Rehabs are not geared up to people with Autism or people on the ‘spectrum’.

Lack of shared perspective: 19/67 (28%)

This theme covered the autistic clients' perceived lack of insight into the therapeutic process (the bigger picture, the aim of the sessions) and a perceived inflexibility to suggestions from the therapist. Sample quotes:

I have found that on times they can't quite see the problem in the situation. They can recognise the trigger for the behaviour, but when discussed ways to eliminate the trigger (Alcohol/drugs) they are unable to find it a problem at this time.

Fixed thinking, self certainty about their choices, have explored all other options for coping with life and have settled on alcohol/drugs, seeing worker as not able to understand or of inferior intellect.

Lack of training: 13/67 (19%)

This theme covered a lack of knowledge about working with autistic clients in the therapist themselves, as well as a lack of knowledge about working with autistic clients in other practitioners. Not knowing what to do if autism was suspected but not disclosed or diagnosed was a specific issue. Sample quotes:

No training in tailoring interventions towards people with autism. The approaches we use which are CBT based may not be useful but as I have not been trained I don't know.

Many ancillary services are not geared up to working with autistics. It is a challenge to put in place the additional support and help they need.

We then asked respondents about any adaptations they had made in treatment/support techniques when working with autistic people in the past. Table 5 highlights the frequency of the adaptations. Typically, therapists reported making between four and seven adaptations for autistic clients (n = 57, 47% of therapists). Eight (7%) therapists reported making between 1 and 3 adaptations for autistic clients and 18 (15%) therapists reported making between 8 and 11 adaptations for autistic clients. Thirty-nine (32%) did not report using any adaptations for autistic clients.

Significantly more adaptations were made by those who had received autism training compared with those who had not received autism training (t(116) = 2.48, p = 0.02). The number of adaptations made by therapists did not significantly relate to number of years working with autistic clients or level of education (r(118) = 0.14, p = 0.133; F(3,99) = 1.08, p = 0.361; respectively).

TCS: adapted for autism

Mean confidence for 88 respondents was 3.44 (SD = 0.74, range = 1.86–5). A one sample t-test highlighted that this mean was significantly higher than the mid-point (3: moderately confident) of the scale (t(87) = 5.59, p < 0.001). All the items had a mean of between 3.00 and 3.99 (moderately confident) with two exceptions. Respondents were more confident that they could “Be empathetic towards an autistic client” (mean = 4.12) and less confident they could “Identify therapeutic approaches that will be effective for an autistic client” (mean = 2.91).

Finally, we explored correlations with therapists' confidence. Enhanced therapist confidence significantly related to receiving autism training (t(86) = 2.21, p = 0.03), the number of adaptations used by the therapist (r(88) = 0.24, p = 0.03), and there was a trend for higher therapist confidence to relate to perceived outcome success (r(71) = 0.20, p = 0.09). Therapist confidence did not significantly relate to highest level of education (F(3,76) = 0.55, p = 0.649).

Therapist guidelines

Members of the autistic and broader autism communities provided their perspective upon how the adaptations from Table 5 could most effectively meet the needs of autistic clients. This process culminated in a “Top 10 tips for therapists with autistic clients” (see the Appendix). This list provides accessible guidance for therapists on how to adapt support in a manner that meets the needs of autistic clients.

Table 5.

Frequency of Therapeutic Adaptations

Using plain language more than with other clients	66 (14%)
A more structured and concrete approach	56 (12%)
Shorter sessions	54 (11%)
Avoiding metaphors in therapy	52 (11%)
Discussing individual hobbies and interests as part of therapy	51 (11%)
More written and visual information than I usually use	49 (10%)
Involving a family member or partner in sessions	37 (8%)
Behavioral strategies to introduce change	33 (7%)
Cognitive strategies to introduce change	32 (7%)
Psychoeducation about emotions	24 (5%)
Longer sessions	8 (2%)
Other (e.g., increasing flexibility, avoiding unexpected events)	18 (4%)

Discussion

This was the first survey of drug and alcohol therapists regarding their service provision for autistic clients. In total, 122 therapists completed an online survey. Overall, the therapists were most likely to be community drug and alcohol service providers educated to diploma level with 10 years' experience (on average) who undertook a wide range of therapeutic approaches. Most therapists had autistic clients and most therapists had received no autism-specific training. Alcohol misuse was the most likely presenting SUD-related issue, and most therapists thought that treatment outcomes were less favorable for autistic clients than for other groups.

In terms of approach, therapists perceived eclectic, family therapy, cognitive behavioral and system2atic approaches to be the most helpful, and a lack of training was one of the barriers to successful intervention for autistic clients. The lack of adaptations for autistic clients was a major barrier as it was clear that a one-size-fits-all approach was not helpful for this group. This may be compounded by a lack of shared perspective between the therapist and the autistic client as to the intended outcomes of the therapeutic process. We have reported a wide array of adaptations to make therapy sessions more autism friendly (Table 5). Members of the autistic and broader autism communities reflected on these adaptations (Appendix).

Overall, therapists were moderately confident that they would be able to deliver effective therapy to autistic clients. Receiving both practical and theoretical training enhanced therapists' confidence and the number of adaptations they made for autistic clients within their therapy sessions as well as perceived outcome success.

These findings highlight the need for therapists to be trained in the wide array of adaptations that can be made to meet the individual needs of autistic clients (and not a one-size-fits-all approach to autism), to reduce the under-representation of autistic clients within drug and alcohol services.^23,25 Around half of therapists reported using between four and seven adaptations for autistic clients, however, around a third of therapists did not report using any adaptations, highlighting the variability in adaptations in therapeutic practice and reiterating the importance of autism-specific training.

This research followed the approach of Cooper et al.²⁹ who explored CBT. They showed that adapting CBT to the autistic client's individual needs has been shown to be effective for autistic people, when adapted appropriately.^32–34 Future research can identify the extent to which adaptations improve alcohol and drug treatment outcomes for autistic clients. It is interesting to note that the drug and alcohol therapists reported being more confident in their capabilities to do this than CBT therapists (Cooper et al.²⁹), although the samples are very different from each other (e.g., Cooper et al.²⁹ report their participants had been working for less time, had different levels of qualification, and had little experience of clients with substance misuse as an issue compared with participants in this study).

This is pertinent as the only consistent finding in research to date is the lack of knowledge among professionals on how to treat this group of service users.^1,4,14,34 The perceived issues and challenges to working with autistic clients came under three headings. By far the largest number of issues came under the “lack of adaptations for autistic clients,” and this is consistent with the quantitative data mentioned. We presented a range of potential adaptations in Table 5 and the Appendix. This is not an exhaustive list of adaptations and each autistic client may benefit from differing combinations of adaptations. It is interesting that the diagnostic challenges with social communication and interaction were discussed in terms of adapting practice rather than in terms of the client.

The second challenge was a lack of shared perspective between the therapist and the autistic client. Traditional theoretical accounts have characterized autism in terms of difficulties with taking the perspective of others, that is, difficulties with “Theory of Mind” or “empathy.”^35,36 More recently, autistic researchers, such as Milton and colleagues, have characterized difficulties with a shared perspective between autistic and nonautistic people as “the double empathy problem.”³⁷ According to the double empathy problem, empathy is a two-way process that depends on expectations from previous social experiences that can be very different for autistic and nonautistic people.³⁸

These differences can lead to difficulties in communication and developing a shared perspective between the therapist and the autistic client (as opposed to just the autistic client having difficulties with a shared perspective), with both therapist and client needing to work on addressing differences in communication styles.^39,40 Crompton et al.³⁸ conclude “By finding out more about how the double empathy problem plays out in real life, we can help non-autistic and autistic people to understand each other better and help them to ‘meet in the middle’ (p. 5).” Within the therapeutic context, explicit negotiation of the aims and outcomes of each session may be a useful way to address any perceived lack of insight or inflexibility between the therapist and autistic client.⁴¹ This is reflected in the “Be explicit” guidance given in the Appendix.

The third challenge faced by therapists was the lack of autism-specific training—both in their own therapy practice and that of their ancillary services. We identified differences between therapists who had and had not received autism-specific training (above), and the findings from the present study indicate that this training needs to be both theoretical and practical to maximize the benefits of training. Again, this is reflected in the “Understand autism” guidance given in the Appendix.

This is consistent with Helverschou et al.³⁴ who found that SUD symptoms can be reduced in autistic adults by providing monthly autism education and group supervision to CBT therapists in general SUD outpatient clinics. The qualitative and quantitative data indicate that therapists are eager to improve their practice for autistic clients through autism-specific training. This study suggests that therapists believe this should focus on adaptations for autistic clients and develop a shared perspective between therapist and client.

The findings are also consistent with previous research that has suggested that alcohol misuse may be the primary substance with SUD associated with autism.^17,18,20,21 If alcohol misuse is related to alleviating anxiety,¹⁸ adapting service provision with this informed perspective could inform the focus of future adaptations.⁴² It was interesting to note that “cannabis” was identified by a small number of therapists within the “other” category of problematic substances, and may also have been reported under illicit drugs or prescribed drugs. As cannabis is becoming increasingly decriminalized for recreational use and legalized for medical use throughout many countries of the world, a better understanding of how autistic people use cannabis would be welcomed.

For example, cannabidiol is one of the naturally occurring cannabinoids found in cannabis plants,⁴³ which is legal and used more excessively by autistic adults compared with nonautistic adults.⁴⁴ Ramos et al.¹⁵ proposed that the literal interpretation of rules may make autistic people less likely to experiment with illegal substances and the increasing decriminalization/legalization of cannabis may make this a particularly timely issue.

This is the first study exploring drug and alcohol practitioners' perceptions of their service for autistic clients and, therefore, needs to be interpreted with caution. A primary limitation is the online nature of the sample. It is not possible to ascertain how representative this sample is of drug and alcohol therapists as a whole. A request to respond to a survey about autistic clients may have biased the sample toward (or even away from) those who had experience with autistic clients. The sample was also U.K. based and there may be different issues that emerge in different cultures. In addition, it was not possible to identify through which route the participants had been recruited.

As therapists had different experiences, different number of therapists responded to different questions (depending upon their experience). Consequently, a limitation is that some questions have a relatively small number of responses, which needs to be borne in mind (e.g., Table 4 highlights that the highest response rate for approaches used by therapists was cognitive behavior approaches, which had 35 responses). Crucially, Table 1 highlights that only around half of therapists have formal processes (referral paperwork, protocols) that enable them to know the diagnostic status of their clients.

Many therapists use informal processes (own judgments, noticing traits) to identify clients as autistic. In addition, the respondents to the questionnaire were therapists and a limitation is that the sample does not include autistic clients. We asked members of the autistic and broader autism communities to reflect on the findings regarding adaptations after the survey data were analyzed. The memberships of the focus groups were convenience samples and we could not confirm diagnostic status, relationship/advocate status, or professional status. In addition, this represents an addition to the established methodology of Cooper et al.²⁹ (after Zervogianni et al.³¹).

Overall, the therapists concurred with the literature identifying that autistic adults report that treatment programs for drug and alcohol misuse do not adequately adapt for the individual needs of autistic clients.^23,24 This is highly pertinent given the requirement under the Disability Discrimination Act (UK) to make reasonable adjustments in order for people with a range of disabilities to access their services on an equitable basis.^3,26 This study identified the perceived success of differing approaches and the range of reasonable adaptations that are being undertaken for autistic clients.

Future research can explore the effectiveness of these adaptions in ensuring favorable outcomes for autistic clients. The study highlights the desire for, and benefits of, autism-specific training for therapists. In addition to sharing best practice regarding adaptations for autistic clients, training should focus upon how to effectively develop a shared understanding of the aims and desired outcomes of the therapeutic process.

Footnotes

Authorship Confirmation Statement

M.B. contributed to conceptualization, methodology, formal analysis, investigation, writing—original draft, writing—review and editing, and funding acquisition. S.A. was involved in conceptualization and writing—review and editing.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This research was funded by the charity Alcohol Change United Kingdom. Grant number: ACUK_UoB.

Appendix. Top 10

Tips for Therapists with Autistic Clients

1. Understand autism

Understand the thinking processes that characterize autism, including potential strengths, and the impact of commonly co-occurring conditions such as anxiety. Training in both theory and practice is ideal. Consider sensory issues before, during, and after each session. Check with the autistic person before any session starts—ask “what do you need?” (e.g., in terms of lighting and noise levels). Can the support be accessed online?

2. Get prepared

This includes consideration of how the client will get to the session (e.g., transport). The first meeting should be in a familiar place. Provide a photo of the therapist and/or the therapy room before the session.

3. Maximize structure and consistency

Have a regular slot, with the same person. Discuss this with the autistic person—9 am starts may be difficult for an autistic person with disrupted sleep, for example.

4. Retain flexibility

Sessions may need to be longer, if clients need to be supported in self-regulation before therapy can begin. Clients may be more likely to miss sessions, and any sanctions (getting discharged) would need to be a last resort. Usual assessments of “motivation to change” (e.g.) may not be appropriate.

5. Use plain language, avoiding nonliteral language (such as “pull your socks up”)

Avoid metaphors, jargon, acronyms. Remember to “keep it simple and straightforward.”

6. Be explicit

Always explicitly explain WHY something is happening. Always have clear aims, with reminders throughout and afterward as to what the aims were.

7. Discuss individual hobbies and interests as part of therapy

This can be useful for identifying motivations and developing resilience. Always be clear why this is being done (to get to know you, to calm down, etc.).

8. Provide written and visual information during the session

Use “Easy read” guidelines and ensure the amount is not overwhelming. Digital supports can be invaluable. Allow time for processing information (verbal or written).

9. Educate about emotions

Emotions need to be discussed in terms of lived experience, not simply labels. “Meltdowns” can be misinterpreted as aggressive, leading to “red flags,” but this may be a misattribution of the underlying emotion. Be aware clients may well have experienced trauma in the past.

10. Involve a family member or partner or advocate in sessions

If this is agreed with the autistic client, the decision should be regularly revisited. With consent separate sessions for family/partner/advocate may be appropriate. The autistic client should remain in control.

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