“Resist,Reframe,Redo the Bullying,the Lying,the Harassment”: A Qualitative Investigation of Social Anxiety and Therapy as an Autistic Person

Abstract

Background:

Autistic people commonly report social anxiety. There may be distinctive aspects of the autistic experience of social anxiety, as well as aspects of therapy for social anxiety that need to be adapted for autistic people. This study investigated these issues through the firsthand perspectives of autistic people.

Methods:

Fifteen autistic adults took part in semistructured interviews about their experiences of social anxiety and cognitive behavioral therapy (CBT) for social anxiety, the first-line intervention for social anxiety. Interviews were analyzed using reflexive thematic analysis.

Results:

Autistic people perceived differences in their experience of social anxiety compared with non-autistic people. These included the impact of (1) autistic traits, (2) traumatic experiences of living in a neurotypical world, and (3) nonsocial factors that contribute to anxiety in social situations for autistic people. Participants also questioned the cognitive and behavioral components of conventional CBT for social anxiety (as they had experienced it); argued for a trauma-informed approach to social anxiety; and explained how the social process of therapy needed adaptation for autism.

Conclusion:

These perspectives will help therapists and researchers refine their formulation of social anxiety in autistic people and inform the development of autism-adapted social anxiety interventions.

Community Brief

Why is this an important issue?

Social anxiety is very common in autistic people. We need to know more about the factors affecting social anxiety in autistic people. This will help us treat it effectively if someone seeks therapy. In addition, we know that autistic people are often failed by mental health services. However, we know very little about how autistic people experience particular therapies. This includes cognitive behavioral therapy, which is the first-line therapy for social anxiety.

What was the purpose of this study?

The first aim was to understand the perspectives of autistic people on what is unique about the autistic experience of social anxiety. The second aim was to understand autistic people’s experiences of cognitive behavioral therapy for social anxiety.

What did the researchers do?

We interviewed fifteen autistic adults to see whether a theory of social anxiety relevant to the general population matched their own experience of social anxiety. We also interviewed them about their experiences of cognitive behavioral therapy for social anxiety. We analyzed common themes across the interviews.

What were the results of the study?

Interviewees highlighted that autism traits, trauma, and nonsocial factors needed to be considered in social anxiety of autistic people. Interviewees felt that cognitive behavior therapy did not meet their needs for social anxiety. They said it wrongly assumed their social fears were irrational; encouraged inappropriate modification of behaviors; and did not consider trauma sufficiently. They also thought therapists did not always adapt therapy sessions to their social/communication needs.

What do these findings add to what was already known?

The findings support other research showing that different factors are important in social anxiety for autistic people compared to non-autistic people, including autism-related and environmental factors. The findings extend previous research by providing novel reflections based on the lived experience of autistic people about an important theory of social anxiety that underpins how we understand and treat social anxiety in the general population. The findings agree with other studies that therapy needs adaptation for autistic people. However, this study goes further by highlighting autistic people’s perspectives on flaws in the fundamental principles of cognitive behavioral therapy for social anxiety.

What are potential weaknesses in the study?

We cannot be sure of the quality of the therapy the participants had received. The participants who were interviewed may have chosen to take part because they had a bad experience of mental health services, which might not be reflective of other experiences. Most participants were highly educated, White autistic adults, who were diagnosed in adulthood, and we cannot know whether their experiences are similar to other autistic adults.

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

The findings include recommendations to therapists in working with autistic adults with social anxiety. The findings will also help researchers further develop modified therapies for mental health difficulties in autistic people.