‘It’s not always textbook social anxiety’: A survey-based study investigating the nature of social anxiety and experiences of therapy in autistic people

Abstract

Little is known about the nature of social anxiety in autistic people: What is similar and different about factors contributing to social anxiety in autistic and non-autistic people? There is also very limited research about autistic people’s experiences of therapy for social anxiety in current routine clinical practice. This study investigated these issues by analysing responses to an online questionnaire for 308 adults with elevated social anxiety (232 autistic people and 76 non-autistic people) using mixed-methods approaches. Distinct factors influenced social anxiety in autistic participants, including individual and environmental factors relating to autistic experiences in the social world. We propose a ‘distinct’ model of social anxiety in autism. In addition, many participants had not had helpful experiences in therapy, especially cognitive behaviour therapy, for social anxiety: They thought therapists did not always acknowledge the basis of their social fears, did not adapt the therapy process in an individualised way and did not understand neurodiversity or recognise neurodivergence. Our results suggest that social anxiety needs to be understood specifically in the context of autism, and if this is neglected, therapy is unlikely to be helpful. Based on participants’ comments, this article makes some practical recommendations for therapists supporting autistic adults with social anxiety. Lay Abstract The nature of social anxiety has been widely researched in non-autistic people. This existing research has allowed therapists to develop effective therapy for social anxiety in non-autistic people. Meanwhile, some research suggests that autistic people may have different experiences of anxiety compared to non-autistic people. In addition, there is some evidence that modified therapy may help autistic people with social anxiety, although we also know that many autistic people feel failed by existing mental health services. This article provides a detailed picture of social anxiety in autistic people. This includes similarities and differences compared to non-autistic people. In terms of similarities, people often described feeling afraid that others would judge them, and this would have negative consequences. In terms of differences, autistic people commonly reported a clash between their traits and their social environment, which caused them distress and discomfort. This included factors only rarely reported by non-autistic people (such as struggling with too much sensory stimulation or inaccessible forms of communication and encountering discrimination for these problems). Based on this, we propose a ‘distinct’ model of social anxiety with particular relevance to autistic people. In addition, many participants reported negative experiences in therapy for social anxiety. They thought therapists wrongly viewed their fears of social situations as irrational and ungrounded. They thought therapists did not adapt the therapy process in an individualised way and did not understand neurodiversity or recognise neurodivergence. Standard approaches for social anxiety may not always suit autistic people, so this needs further exploration. We highlight several practical recommendations for therapists offering therapy for social anxiety to autistic people.