Dr Claire Evans-Williams Highly Specialist Clinical Psychologist NHS/STAG Psychological Services/ The Autism Academy U.K

Intended Learning Outcomes Identify the ways in which an autism assessment may arise within clinical settings Describe the challenges with identification and diagnosis of autism in adults within a mental health context Review the clinical guidelines for psychotherapeutic support with autistic adults Describe the "Autistic Hierarchy of Need" model

Overview Common reasons why an adult autism assessment might arise Challenges of identification and diagnosis of autism in adults Limitations of the diagnostic and therapeutic guidelines Case Study: Julia

Common reasons leading to adult Autism assessment Individual-led enquiry: "I'm struggling to cope and I need help with my mental health difficulties" "I'm struggling to manage life and I don't know why" "I watched a programme about autism I think I'm autistic" "My son/daughter/ brother/sister has recently been diagnosed could I be autistic too?" "My friend/teacher/dentist thinks I'm probably autistic do you think I am?"

Common reasons leading to adult Autism assessment Professional-led enquiry: "I've been working with this person for over a year and we're not getting anywhere. Are they autistic?" "My client doesn't make good eye contact, and likes spending time on their own.. Could they be autistic?" "Anxiety management strategies aren't working. Could autism be the answer?" "Something's just not adding up. I'm stuck. Can you assess my client, and offer your opinion?"

Challenges to identification & diagnosis

SIGN: Levels of evidence

No evidence base(?)

Expert opinion

Diagnosis achieved. What next?

Extrapolate from child research

What I hear a lot!!! AUTISM + ANXIETY = INEVITABLE Conclusion: Controlled relaxation breathing Mindfulness exercises Guided imagery Graded exposure to anxiety trigger Discharge from service

My response

Followed by

Introducing Julia

"Hoping for promotion" but falling behind at work Worried about living alone Being awake at night has "always been a problem" Julia Arguing a lot with my friend Headaches, feel sick, & need to be alone "Who am I?" - Feeling lost in my life.

SELF-ESTEEM Executive functioning challenges = Organising workload is hard PERSONAL SAFETY Lack of safety/ communication strategies = risk of harm SLEEP Use of TV and ipad in bed arousal = Unhelpful sleeping practices Julia + "anxiety" RELATIONSHIPS Challenges with social imagination = Misunderstandings with friend SELF-IDENTITY Changing myself to "fit in" with others = Who am I? Feeling lost SHUTDOWNS Masking/ mimicking & sensory overload = Exhaustion & feeling unwell

Evans-Williams (2017) Autism Needs Hierarchy

Physiological Needs Food: nutritional advice, cooking skills, meal timetable Rest: sleep hygiene, worry timetable, melatonin Shelter: appropriate environment & adaptations Sensory: light, noise, smell, tactile, hypo/hyper sensitivity Behavioural coping strategies: "shutdown" "meltdown" Addressing risk of harm: self-care, suicidality, self-harm.

Safety Needs Violence: Bullying, domestic violence, sexual abuse, psychological Monetary: financial exploitation, debts, benefits advice Employment: job stability, discrimination in the workplace

Relationship Needs Family & friendship: exploring social imagination challenges, proactive communication Love & intimacy: how to find a partner, relationship maintenance, conflict resolution Colleague interactions, group working: disclosure, & occupational support

Self-Esteem Needs Self-efficacy: develop necessary skills to support development in desired area identified; Confidence building: Goal orientated tasks, behavioural experiments; cognitive appraisal Sense of self via others: Gathering evidence and feedback from close friends, relatives, and assimilating this to develop new beliefs

Self Identity Needs Exploring positive skills, attributes, characteristics: musical; artistic; technical; logical; nurturing/ empathy; sense of social justice Reviewing the past: using autism tinted spectacles to make sense of experiences in the past (may include complex trauma intervention) Introduce models of disability: Social model of disability appears to develop self-empowerment and in creating a sense of shared-identity with autistic community

Self-giving Needs Evolving and strengthening: Continual reflection on the development of self-concept via interactions with others and engagement in the following: Contribution to the community: meaningful and worthwhile pursuit of "giving-back" to others- autism; art; sport; academia; work-place Self-care: self-compassion and acceptance of self as a holistic being; appropriate adherence to mental & physical health regimen; appropriate help-seeking when needed.

Critique Grounded in existentialist philosophy Linear acquisition of need Further refinement & detail required Ecological validity Efficacy testing

@DrEvansWilliams Questions