Saturday, April 27, 2013

Adult Autism, Avoidance and Depression

In my work with adults on the spectrum I help adult clients take a look at a big theme: avoidance.

Avoidance is a theme, but not a constant pattern.  I've worked with many clients who, once they're interested in a task or problem, are the hardest workers I've ever known.

Yet these same clients may struggle with avoidance when it comes to everything from personal hygiene to buying Christmas presents.  It's puzzling to those around them, and even more puzzling to themselves.  Why can other people seem to "get it together" and "buckle down"?  Even clients who are functioning well are plagued by avoidance that causes anxiety and schedule disruption: a three-week project is avoided until the night before, then powered through at the last minute.  It's not as though the three weeks of avoidance were spent in blissful denial; rather, most clients describe an anxious, mental circling feeling that leaves them feeling dread.  So why not just approach the task earlier? Most determine that it must be a character failing.  What other reason could there be?

This avoidance may be depression in disguise.  Together, clients and I have come to understand that the autistic experience of depression often involves something other than the standard sadness we all associate with depression.  The autistic version of depression is dominated by apathy, and a pretty profound inertia that can make it hard to approach tasks or even move physically.  With our newer understanding of how depression's lowered dopamine levels impact motivation and drive, not just mood, (see, this does make sense.  Still, recognizing depression when it doesn't necessarily involve a subjective sense of sadness, can be tricky. And that means that typical treatments that address sadness can be not only ineffective, but irrelevant.

More effective, you might think, is addressing the behavioral side of therapy.  The behaviors of getting up, showering, getting some exercise, etc, etc, etc.  Surely focusing a bit on these aspects of healthy functioning is not irrelevant, but it's no fix, either.  For clients on the spectrum, work is to be done for a purpose.  A demand for purposeless work, or what feels like purposeless work, can actually exacerbate avoidance symptoms.

In my experience, clients on the spectrum who are dealing with avoidance as a powerful symptom of depression, are dealing with a symptom whose roots are in feelings of meaninglessness.  Folks on the spectrum often find meaning through curiosity - once that door is closed, it's difficult to manage mood and motivation.  In fact, it may be that the "special interest" phenomenon we see with autistic adults is the just the behavioral manifestation of the mood-altering function of learning.  So treatment - at least short-term treatment - for depressive symptoms often involves learning of some sort.

If you have a loved one on the spectrum who is struggling with avoidance as a symptom of depression, it may help to know that many clients describe feeling confused and helpless as to why the problem of avoidance persists. While avoidance may at times look oppositional ("Why can't he just remember to take out the bins on Thursday? Why is it always my job?"), I rarely have found this to be the case.

Identifying the mood components of the behavior is crucial to understanding why the problem exists and how to begin solving for it.  As we all know, nagging, reminding, lists, threats and even real-world consequences often are of no help.

As I work with more and more adults on the spectrum over time, it seems to me that it is crucial that mood is carefully assessed.  This can be tricky - if the autistic adult cannot self-report sadness (either because it is not felt or not identified), and if many of the behavioral markers of depression are missing (no tearfulness, suicidality, missed work, diet changes, etc), depression can be, and is often, missed.  If it is, the behaviors that keep depressive symptoms at bay will be intractable, and psychotherapy will devolve into going in circles.  This can be especially demoralizing for couples.

If you or a loved one is looking for help, working with a clinician experienced in autism in adults is crucial, so that symptoms that present much differently in the autistic individual can be identified and treated.  And above all, so the autistic individual can have the experience of being seen.