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Autism in Couple Relationships

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Autism in Couple Relationships

Part of the early appeal of dating an autistic person for a person who is not autistic can be a sense that they are different that they have a mind that can grasp astonishing complexity, they are wonderfully attentive, have deep compassion, are fair-minded, are very talented in their field, extremely loyal or different in ways that are intriguing but not yet fully apparent. Indeed the early stages of dating may not indicate the long-term relationship issues that can occur. On both sides, there can be expectations of how a long-term relationship “should” be, each informed by their own culture or way of thinking. We have learned through our vast clinical experience that approaching relationships between autistic and non-autistic individuals can be likened to a cultural exchange programme, where there needs to be understanding and acceptance of each person’s culture for the relationship to succeed. Certainly, this is true in all relationships but it plays out more significantly when one partner in the relationship is autistic.

The early stages of dating may not indicate the long-term relationship issues associated with autism. The autistic partner may have initially camouflaged and suppressed their autistic characteristics to be more attractive to a non-autistic partner. They may have acquired a dating ‘script’ from watching romantic movies and created a ‘mask’ or artificial persona. However, gradually the mask is removed, and it becomes apparent that the autistic partner does not intuitively know long-term relationship skills.

Theory of Mind

Some of the issues in the relationship can be due to aspects of ‘Theory of Mind’, a psychological term that describes the ability to read facial expressions, body language, tone of voice and social context to determine what someone is thinking or feeling. Both partners experience this. We have known for some decades that autism is associated with Theory of Mind difficulties, and these are part of the diagnostic criteria. However, the non-autistic partner can also have difficulty ‘reading’ the inner thoughts and feelings of their autistic partner. This is described as the Double Empathy issue (Milton, 2012). The autistic partner may not express subtle emotions in facial expressions, tone of voice and body language.

In a conversation, the autistic partner can struggle to find the words to express thoughts and feelings due to aspects of interoception and alexithymia. That is the sensory perception of the body signals that indicate emotional states such as heart rate and breathing (interoception) and being able to translate the emotions that you feel or remember into speech (alexithymia). This will affect the ability of the autistic person to disclose their inner world and communicate their feelings. As the relationship progresses, the non-autistic partner will anticipate increasing self-disclosure as a sign of the depth of the relationship and trust. The non-autistic partner must recognise that their autistic partner has genuine difficulty perceiving and communicating their inner world.

Social engagement

Autistic adults can achieve successful social engagement, but this may be by intellect rather than intuition and often with social guidance from the non-autistic partner. Social occasions are mentally exhausting and energy-draining. In contrast, the non-autistic partner may find that social experiences require little mental energy and may create energy. The non-autistic partner may reluctantly agree to reduce the frequency and duration of social contact with family, friends, and colleagues for the sake of the relationship but feel deprived of experiences they enjoy.

The non-autistic partner may also recognise that their autistic partner can engage socially at work but, on returning home, is exhausted and actively seeks solitude or engagement in a hobby or interest as a means of energy recovery. Although the couple lives together, the autistic partner has a diminishing need for social, conversational and leisure time together. An issue for the non-autistic partner is feeling lonely within the relationship.

Communication

One of the consequences of difficulties with Theory of Mind abilities is misinterpreting intentions, such as determining whether a comment or action was deliberately malicious, humorous or benign. This can lead to conflict within the relationship, with either partner being quick to take offence.

Another communication issue is a tendency for the autistic partner to be perceived as overly critical and correcting and rarely providing compliments. They intend to improve their partner’s proficiency and anticipate gratitude for their advice, being unaware of the effect on their partner’s self-esteem. There may also be a reluctance to provide compliments due to not intuitively knowing that in a relationship, the non-autistic partner need for regular approval and admiration and reluctance to give a compliment when their partner is already aware of their achievement.

As the non-autistic partner describes their daily experiences, their autistic partner may not engage in the anticipated degree of eye contact and words, sounds, and gestures of compassion and interest. The autistic partner absorbs the story but does not appear attentive and is eager to provide practical advice rather than non-judgemental listening and empathy. The non-autistic partner can feel they lack emotional support but experience considerable practical advice.

Expressions of love and affection

In a conventional relationship, regular expressions of love and affection are expected. A metaphor for the need and capacity for expressions of love and affection can be that a non-autistic partner has a ‘bucket’ capacity for love and affection that needs to be regularly filled and replenished. In contrast, an autistic partner has an affection ‘cup’ capacity that is quickly filled. The autistic partner may be perceived as not expressing sufficient affection to meet the needs of his or her partner, who feels affection deprived and unloved, which can contribute to low self-esteem and depression.

When the autistic partner recognises the value of expressions of love and affection in the relationship, there can be the issue of the frequency, type, intensity and duration of expressions of love and affection. As an autistic partner said: ‘We feel and show affection but not enough and at the wrong intensity’ and “I know I am not meeting her needs, but I don’t see them, will I ever be able to make my partner happy”. A non-autistic partner gradually realised that “…he can’t give me my needs because he doesn’t see them, he doesn’t perceive them and doesn’t ask about them… I often feel alone in our relationship because he’s not quite with me” (Smith et al., 2021)

Emotion repair

During personal distress, when expressions of empathy and words and gestures of affection would be expected as an emotional restorative, the autistic partner may not read the signals to elicit emotion repair (Theory of Mind) or know and have confidence in what to do. Their emotional repair mechanisms may be solitude and engaging in their interests and hobbies as a thought blocker. Affection may not be perceived as an emotion repair mechanism, with a hug perceived as an uncomfortable squeeze which does not automatically make them feel better. A typical comment of the non-autistic partner is that hugging their autistic partner is like ‘hugging a piece of wood’. The person does not relax and enjoy such close physical proximity and touch.

Being alone is often the primary emotional repair mechanism for an autistic partner, and they may assume that is also the case for their non-autistic partner, with the thought that if I leave her alone, she will get over it quicker. They may also not know how to respond or fear making the situation worse, as in the relationship counselling session where an autistic partner sat next to his wife, who was in tears. He remained still and offered no words or gestures of affection for emotional repair. When asked if he knew his wife was crying, he replied, “Yes, but I didn’t want to do the wrong thing.”

The autistic partner can be accused of being callous, emotionally cold and lacking empathy due to a genuine difficulty reading interpersonal signals and knowing how to respond. The non-autistic partner gradually realises that they need to be very clear and direct in expressing their feelings and suggesting to their partner what they need to do for emotion repair.

Intimacy

There may be issues associated with verbal, emotional and physical intimacy. The effects of alexithymia will inhibit verbal and emotional intimacy, that is, converting thoughts and feelings into speech. However, an autistic partner may be able to express their thoughts and feelings indirectly using music, poetry, a scene from a movie, a passage in a book or typing rather than speaking their thoughts and feelings.

Sensory sensitivity may affect physical intimacy, leading to confusion, distress, and frustration with sexual experiences for an autistic partner (Gray et al., 2021). Autism is associated with a low or high threshold for sensory experiences, especially tactile experiences. A low threshold can lead to experiencing discomfort or pain when lightly touched during moments of intimacy. A high threshold can lead to requiring greater physical stimulation, as in the comment from the Gray et al. research paper, “I am not particularly sensitive, so I need more friction to achieve orgasm”. There may also be the issue of the use of drugs and alcohol, as in another comment from the same research study. Only when I am drunk do I feel comfortable being touched or touching others.

There can be issues with the frequency and quality of physical intimacy, which influences sexual satisfaction (Boling, 2016). Sex can become an intellectual interest for an autistic partner in acquiring information on sexual diversity and activities, often from pornography, and sex may function as a means of self-calming and emotion regulation. This was described by one of the participants in the Gray et al. (2021) study “I went through this highly sexualised phase because I just loved the way orgasms made me feel and connected me to myself and centred me. It was like the best self-regulation strategy I had found” The desire for and frequency of sexual activities and experiences may not be reciprocated by the non-autistic partner.

However, from our extensive clinical experience, the non-autistic partner is more likely to be concerned about the lack of sexual desire rather than an excess. The autistic partner may become asexual once he or she has children. In a relationship counselling session, the partner of an autistic man was visibly distressed when announcing that she and her husband had not had sex for over a year. Her autistic husband appeared confused and asked, “Why would you want sex when we have enough children?”

Partnership

In modern Western society, we have replaced the word husband or wife with the word partner. This reflects changing attitudes towards long-term relationships. There is an expectation of sharing the workload at home, for domestic chores and caring for the children, and being each other’s best friend regarding the disclosure of thoughts and feelings, reciprocal conversation, sharing experiences and emotional support. Taking on the role of a best friend is not easy for an autistic partner to achieve due to having lifelong difficulties making and maintaining friendships.

For those autistic adults who have problems with executive function, that is, organisational and time management abilities, distractibility and prioritisation, procrastination and completing tasks, the non-autistic partner often takes responsibility for the family finances, ensuring jobs are completed and resolving the organisational and interpersonal problems that have developed in their partner’s work situation. The non-autistic partner takes on the executive secretary/ mother role, frequently prompting their partner on what to do (Wilson et al., 2014). This aspect of the relationship adds to the stress and responsibility of the non-autistic partner and can be a source of conflict in the relationship.

Conflict management

In any relationship, there will inevitably be areas of disagreement and conflict, such as having different parenting styles. Unfortunately, autism is associated with a developmental history of limited ability to manage conflict successfully. The autistic partner may not be skilled in negotiation, accepting alternative perspectives, agreeing to compromise, and the art of apology and may tend to hold and ruminate over grudges. This can be due to difficulty with understanding the thoughts, feelings and perspectives of others, a central characteristic of autism and limited experiences of childhood and adolescent friendships where these abilities are practised. Effectiveness in resolving conflict is a factor in relationship satisfaction for both the autistic and non-autistic partner (Bolling, 2016).

Emotion management

Autism is associated with experiencing strong emotions, especially anxiety, anger and despair and difficulty coping with stress at work and home. (Attwood 2006). There may be issues in the relationship regarding anxiety because the autistic partner can be very controlling, and life for the whole family is based on rigid routines and predictable events. There may be concerns regarding anger management and the risk of physical and psychological abuse (Arad et al., 2022), and both partners may be vulnerable to being depressed (Arad et al., 2022; Gotham et al., 2015). The relationship may benefit from assessing specific mood disorders and appropriate treatment and professional support.

Mental and physical health

Surveys of the mental and physical health of couples where one partner is autistic indicate that the relationship has very different health effects for each partner (Arad et al., 2022; Aston, 2003). Most autistic male partners considered that their mental and physical health had significantly improved due to the relationship. They stated they felt less stressed and would prefer to be in the relationship than alone.

In contrast, most non-autistic partners stated that their mental health had significantly deteriorated due to the relationship. They felt emotionally exhausted and neglected, and many reported signs of clinical depression (Lewis, 2017). A sense of grief may be associated with losing the hoped-for relationship, as illustrated by the comment, “It’s not only what I’ve lost, it’s what I’ve never had… (Millar-Powell & Warburton, 2020). Most non-autistic survey respondents also stated that the stress associated with the relationship had contributed to a deterioration in physical health.

Thus, we increasingly recognise the potential benefits of couples engaging in relationship support and counselling, which focuses on assisting their clients in identifying each other’s needs and how best to meet them (Yew et al., 2023).

References

Arad, Schectman and Attwood (2022). Journal of Psychology and Psychotherapy 12

Aston (2003) Asperger’s in Love: Couple Relationships and Family Affairs London, Jessica Kingsley Publishers.

Attwood, T. (2006). The Complete Guide to Asperger’s Syndrome London, Jessica Kingsley Publishers.

Bolling (2026) Asperger’s Syndrome/Autism Spectrum Disorder and marital satisfaction: a quantitative study Antioch University, New England.

Gotham, Unruh and Lord (2015). Autism 19

Gray, Kirby & Holmes (2021). Autism in Adulthood 3

Lewis (2017) Journal of Marital and Family Therapy 43

Millar-Powell and Warburton (2020). Journal of Relationship Research 11

Milton, D. (2012.) Disability and Society 27

Smith et al., (2021) Journal of Autism and Developmental Disorders 51

Wilson, Beamish, Hay & Attwood (2014). Journal of Relationship Research 5

Yew, Hooley & Stokes (2023). Autism in press.

Autism and Substance Addiction

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Autism and Substance Abuse

We have seen an increasing number of autistic adolescents and adults with signs of substance addiction, usually alcohol but also illegal substances such as marijuana, amphetamines and opiates and the misuse of prescription medication such as benzodiazepines. Why are autistic individuals at risk of developing substance addiction? The simple explanation is to engage or escape reality and moderate intense emotions.

Engage reality

A fundamental characteristic of autism is difficulty socialising and subsequent social anxiety. Alcohol and marijuana can be used as a relaxant in social situations. The autistic person may find socialising easier when mildly intoxicated, with a sense of calmness and competence. An autistic adult explained Alcohol makes verbal communication easier (Brosnan & Adams, 2020). Unfortunately, the autistic person may depend on these substances to facilitate social engagement. An autistic adult explained: Alcohol is relaxing and provides happiness, and another autistic adult said that alcohol is A central solvent that my body chemistry has been missing. Alcohol is my cure for anxiety. Marijuana can have similar effects I smoke pot to make my anxiety and autism go away. It’s the only time I feel on the same wavelength as everyone else (Weir et al., 2021).

At the end of the working day, when a non-autistic person is exhausted and stressed, they may seek energy replenishment and relieve their tension via compassion, gestures of affection and conversation from a supportive person in their life. These interpersonal energy and emotion repair mechanisms may be less effective for an autistic person. Alcohol may be their preferred means of relaxation, and a daily routine of alcohol consumption becomes established.

Another characteristic of autism in adolescence is the tendency to be rejected by peers, engendering feelings of a lack of connection and not belonging to any specific group or culture. The acquisition and consumption of alcohol and drugs – easily available and the ‘currency’ of popularity and status – can provide membership in a sub-culture composed of others who also do not fit into conventional society. This group accepts those who are not popular. This sub-culture has clear rules and expectations regarding how to dress, talk and behave and has its own language and rituals. Friendships are formed, and the person is warmly welcomed, especially if he or she colludes with group members to acquire mood-altering substances, and the autistic group member avidly acquires knowledge on drugs from the Internet and becomes the respected expert for members of the group to consult on drug effects, dosage and interactions.

Many autistic adolescents and adults have extreme anxiety levels and describe trying to cope with racing thoughts, which are difficult to slow down, and ruminations, which are extremely difficult to block. Alcohol and drugs especially opiates and marijuana, can decelerate thoughts that are speeding out of control and block ruminations. 

Some medications prescribed to reduce anxiety, such as benzodiazepines, can themselves become addictive after several months, with the person developing increased tolerance, impaired cognitive abilities, memory problems and mood swings. There can also be a dangerous misuse of other prescription medications and substances as the person self-medicates for anxiety, with the potential for hazardous drug interactions and the very real danger of accidental overdose. There is also the risk of conflict with the law and entry into the Criminal Justice System (Attwood, 2019).

Another contributory factor for an autistic person to maintain substance addiction is ADHD. We know that most autistic individuals also have signs of ADHD which can lead the autistic addict to be impulsive and not consider the long-term consequences of drugs on themselves and their family, and want almost instantaneous relief from intense and unbearable emotions, especially anxiety. Psychological emotion regulation strategies such as cognitive behaviour therapy, mindfulness and Yoga take time and effort.

There are high levels of unemployment associated with autism, leading to boredom, frustration and a sense of uselessness and under-achievement. Being part of the drug culture can provide purpose and structure for the day. There is a sense of achievement in seeking and finding drugs and an opportunity to leave one’s accommodation and meet people within the drug culture.

Escape reality

The use of mind-altering substances can provide a sense of protection, ‘anaesthetising’ the person from the effects of past trauma, such as being bullied or being the victim of emotional, physical, financial, or sexual abuse.  Being in an emotionally safe ‘bubble’ creates a sense of emotional detachment. An autistic addict described self-medication as an escape from pain and genuine relief.

Alcohol, marijuana and illegal drugs seem to suppress or ‘switch off’ the frontal lobes, the thinking part of the brain. Autistic individuals need their frontal lobes to efficiently process social information and cognitively moderate emotions. When intoxicated, an autistic person may increase their autistic characteristics and have impaired decision-making, affecting their quality of life.

Research on autism and substance addiction

Rengit et al. (2016) confirmed our clinical experience that substance use for autistic individuals often alleviates anxiety and inclusion in a subculture. The association with autism, ADHD and substance abuse was confirmed by Butwicka et al. (2017). The same study found that substance use-related problems have been observed among 19%-30% of adult autistic clients in general clinical settings. A study of consecutive intake assessments at a substance use disorder clinic for young adults using a screening instrument for autism found that 20% had autistic characteristics (McKowen et al., 2021). 

A systematic review of relevant research by Ressel et al. (2020) suggested that up to 36% of autistic individuals have co-occurring issues with substance abuse. An online survey of over 500 autistic adults found that the rate of heavy episodic drinking was 54%, with the rate in the non-autistic population being 17%. (Brosnan and Adams 2020). The strongest motivations were for social reasons and to enhance positive feelings, and 45% indicated they would not seek support for their substance use, with barriers to support including that it would occur in an unfamiliar chaotic environment and anticipating being misunderstood and judged by rehabilitation staff.

What to do when there are signs of addiction

The first stage is to recognise the addiction, which may affect mental and physical health and family dynamics and potentially lead to criminal activities to pay for the substances. The person who has the addiction may lack insight into the depth of the addiction, failing to recognise their inability to cope without mind-altering substances. If there is recognition of the addiction, there nevertheless may be resistance to reducing the level of substances or engagement in the drug culture, as the person may not be able to conceptualise life without their support in regulating emotions and disengaging from the drug culture. The idea of ‘kicking the habit’ can be frightening because it involves the unknown and trusting the effectiveness of alternative emotion management and social engagement strategies.

The second stage is to address the dysfunctional use of substances. This may mean providing alternative prescribed and carefully administered, and supervised medication. Throughout this process, access to a clinical psychologist is beneficial to provide advice, treatment and support for anxiety management and fear of being able to cope without illegal or misuse of legal substances, to encourage the development of social skills, new social networks and a resilient sense of self.

While the diagnosis of autism may provide a rationalisation for the addiction, it must also be considered when accessing support and therapy services. There will be those who enter the treatment services for addiction who have undiagnosed autism; it is important that there is routine screening for autism in all new participants in rehabilitation therapy and services for addiction, not only to determine the possible reasons for the addiction but also, importantly, to modify the therapy according to the characteristics of autism.

Rehabilitation services often rely on social living and group therapy and provide limited personal space and solitude opportunities. An autistic client will benefit from a single room wherever possible. They will also need guidance and support in group therapy’s social and disclosure requirements due to the characteristics of alexithymia, that is, converting thoughts and feelings into conversational speech. In a rehabilitation service, reading social and interpersonal dynamics can be difficult for an autistic person as well as recognising social and personal boundaries, knowing when to talk and not talk in a group, understanding how to resonate with the experiences and emotions of fellow addicts, and acknowledging the relevance of self-disclosure in a group setting. Staff need to know of these autistic characteristics and must make appropriate accommodations.

A study by Helverschou et al. (2019) found that typical interventions for treating addiction are often unsuitable for autistic adults. They recommended regular staff education on autism and accommodating the characteristics of autism in group sessions. The study also affirmed the perception of autistic participants in therapy as being drug experts and providing advice to staff and fellow residents on drug doses and combinations of drugs. The research also identified a tendency for autistic individuals to end their drug use their own way and not follow a recommended reduction plan.

Our clinical experience confirms that sometimes the autistic person can decide to end an addiction without a therapeutic plan and support. This takes great determination and relies on one of the characteristics of autism: once a decision has been made, the person is unwavering in seeking a resolution and the desired outcome.

A recent survey of over 100 drug and alcohol therapists’ perceptions of current service provision for autistic clients found that most therapists had received no autism-specific training, with alcohol misuse as the most common presenting issue, and most therapists reported that treatment outcomes were less favourable for autistic clients (Brosnan & Adams, 2022). They found an eclectic approach to be the most helpful and psychodynamic least helpful. Autistic clients tended to lack insight into the therapeutic process, were resistant to therapy suggestions, considered therapists as not understanding them or had inferior intellect. The authors recommend a range of therapeutic adaptations, such as using plain language, a more structured and concrete approach, shorter sessions and using hobbies and interests as part of therapy and more written and visual information.

The stress of group engagement, accepting treatment models, and staff not understanding autism can lead to premature voluntary discharge from residential rehabilitation services. The autistic person may become convinced that such services can never be effective. Rehabilitation services need to become more autism-friendly, and psychologists and psychiatrists need to develop an addiction treatment model specifically designed for the characteristics of autism and reasons for substance addiction in collaboration with autistic adults who are or were addicted to substances.

Once the addiction seemingly ends, there is still the risk of relapse. It is important for the autistic person and their family members to accept lapses before there is complete and enduring freedom from addiction. It will be important that the person does not interact with previous drug associates, the associated culture and potential triggers. There will need to be support for stress and emotion management, encouragement to increase the network of social contacts and enjoyable social experiences, and the introduction of a new lifestyle and schedule of daily activities. Recovering from addiction is a long road, but the journey and destination may be lifesaving.

Resources

Jackson (2016). Sex, drugs and Asperger’s syndrome London, Jessica Kingsley Publishers

Kunreuther & Palmer (2018). Drinking, drug use and addiction in the autism community London, Jessica Kingsley Publishers

Regan (2015) Shorts: Stories about alcohol, Asperger syndrome and God  London, Jessica Kingsley Publishers

Tinsley & Hendrickx (2008). Asperger syndrome and alcohol: drinking to cope? London, Jessica Kingsley publishers

References

Attwood W.  (2019). Asperger’s Syndrome and Jail: A survival guide London, Jessica Kingsley Publishers

Brosnan & Adams (2020). Autism in Adulthood

Brosnan & Adams, (2022) Autism in Adulthood

Butwicka et al. (2017). Journal of Autism and Developmental Disorders

Helverschou et al. (2019) Substance Abuse: Research and Treatment

McKowen et al (2021) The American Journal of Addictions

Rengit et al. (2016) Journal of Autism and Developmental Disorders

Ressel et al. (2020) Autism

Weir et al. 2021 Lancet Psychiatry

Autism and addiction

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Autism and addiction

It used to be assumed that those who have an Autism Spectrum Disorder are not at greater risk of developing an addiction than those with any other developmental disorder. However, in my own clinical practice. I have seen an increasing number of adolescents and adults with ASD who have signs of addiction, primarily alcohol and drug dependency, and excessive time engaged in computer games. The question has then arisen as to why someone with an ASD is predisposed to develop such an addiction. The simple explanation is either to engage reality or to escape reality. To explain this seemingly contradictory statement, the specific characteristics of ASD need to be considered.

One fundamental characteristic of ASD is a difficulty socializing with, and being accepted by, peers. The machinery of social engagement creaks and squeaks, and alcohol and marijuana can act as social lubrication. The person with ASD may find socializing easier when mildly intoxicated; substances such as alcohol, marijuana and other drugs reduce social anxiety, and create a sense of relaxation and competence. Unfortunately, the person may then become dependent on these to facilitate any social engagement.

Another characteristic of ASD in adolescence is the tendency to be rejected by peers, engendering feelings of not belonging to any specific group or culture. The acquisition and consumption of alcohol and drugs – easily available and the ‘currency’ of popularity and status – can provide membership of a sub-culture composed of others who also do not fit into conventional society. However, they do accept those who are different and marginalized. This sub-culture has clear rules and expectations in how to dress, talk and behave, and has its own language and rituals, ‘friendships’ are formed, and the person is warmly welcomed, especially if he or she becomes a drug courier or supplier. Thus, for the wrong reasons, the person with an ASD belongs to a group and is accepted and valued by peers.

In the case of gaming, there can be an intense engagement, which provides a sense of achievement and identity, often through natural talent and considerable practice. The achievements in group player games on the Internet can lead to the person being popular with fellow gamers, who seek and admire his or her abilities, knowledge and guidance. When playing the game there is little, if any, social chit chat, and no requirement to process non-verbal communication or follow social conventions. The game provides excitement, respect and popularity, and becoming an avatar creates an enjoyable alternative reality.

Many of my clients describe trying to cope with racing thoughts, which are difficult to slow down, and ruminations that are extremely difficult to block. Alcohol and drugs can induce a deceleration of thoughts that are speeding out of control, and can stop ruminations.  Computer games can also be a very effective thought blocker to both ruminations over past events, and persistent negative thoughts that lead to low self-esteem and depression. These games can also act as an energizer when the person is socially and emotionally exhausted.

We recognize that around 85 per cent of those who have ASD also experience high levels of anxiety. Alcohol and drugs, both legal and illicit, can provide relief from constant feelings of anxiety. Some medications prescribed to reduce anxiety, such as the benzodiazepines, can themselves become addictive, with the person developing increased tolerance. There can also be a dangerous misuse of other prescription medications as the person self-medicates for anxiety, with the potential for a hazardous interaction of substances, and the very real risk of accidental overdose.

There are high levels of unemployment associated with ASD, leading to boredom, frustration and a sense of uselessness and under-achievement. Being part of the drug or gaming culture can provide purpose and structure for the day. There is a sense of achievement in seeking and finding drugs, and an opportunity to leave one’s accommodation and to meet people. Completing the various levels of the computer game can also provide structure and achievement, and the development of expertise that is recognized and valued by fellow gamers.

The use of substances or engagement in computer games can provide a sense of protection, ‘anaesthetizing’ the person from the effects of past trauma, such as being bullied, or being the victim of emotional, physical, financial or sexual abuse.  The addiction may alleviate any feelings of depression about the past, the current situation and future prospects.

Thus, there are many reasons why someone who has an ASD is vulnerable to developing an addiction. The next question is what to do when there are signs of addiction.

The first stage is to recognize the addiction, which may be affecting mental and physical health, and sometimes, as in the case of substance abuse, leading to criminal activities to pay for the substances. The person who has the addiction may lack insight into the depth of the addiction, failing to recognize their inability to cope without mind-altering substances or access to gaming. If there is recognition of the addiction, there nevertheless may be resistance to reducing the level of substances or engagement, as the person may not be able to conceptualize life without their ‘prop’.

The second stage is to address the dysfunctional use of substances and games. In the case of drugs, this may mean providing prescribed and carefully administered and supervised alternative medication. In the case of computer games, the amount of time gaming can be gradually reduced, and a wider range of activities encouraged, providing a sense of achievement and social engagement. Throughout this process, access to a clinical psychologist is beneficial, to provide advice, treatment and support for anxiety management, and to encourage the development of social skills and new social networks.

While the diagnosis of ASD may provide a rationalization for the addiction, it must also be considered when accessing support and therapy services. There will be those who enter the treatment services for addiction who have undiagnosed ASD; it is important that there is routine screening for ASD of all new participants in rehabilitation therapy and services for addiction, not only to determine the possible reasons for the addiction, but also, importantly, to modify the therapy according to the characteristics of ASD.

Rehabilitation services often rely on social living and group therapy and activities, and provide limited opportunities for personal space and solitude. The person with an ASD will benefit from a single room wherever possible. They will also need guidance and support in the social and disclosure requirements in group therapy. For example, there can be difficulties recognizing social and personal boundaries, converting thoughts and feelings into speech, knowing when to talk in a group, understanding how to resonate with the experiences and emotions of fellow addicts, and acknowledging the relevance of self-disclosure in a group setting. Staff need to know of these characteristics of ASD and must make appropriate accommodations.

The stress of group treatment and of staff not understanding ASD can lead to premature discharge from residential rehabilitation services. The person with an ASD may well become convinced that such services can never be effective. I would very much like to see rehabilitation services becoming more ASD friendly, and the development of an addiction treatment model specifically designed for those who have an ASD.

I have found that sometimes the person with an ASD can decide to end an addiction without therapeutic support. This takes great determination, and relies on one of the characteristics of ASD, namely that, once a decision has been made, the person is unwavering in seeking resolution and the desired outcome. However, the recommended treatment is conventional rehabilitation services and continuity of support.

Once the addiction is seemingly at an end, there is still the risk of relapse. It is important for the person with an ASD and their family members to accept lapses before there is complete and enduring freedom from addiction. It will be important that the person does not interact with previous drug or gaming associates, the associated culture and potential triggers. There will need to be support for stress and emotion management, encouragement to increase the network of social contacts and enjoyable social experiences, and the introduction of a new life style and schedule of daily activities. There will also need to be consideration of harm reduction and controlled usage versus total abstinence. Recovering from addiction is a long road, but the journey and destination may be life saving.