Setbacks and Successes: How Young Adults on the Autism Spectrum Seek Friendship

Abstract

Objective:

To describe the perspectives of young adults on the autism spectrum about how they seek and make friends and explore the diverse ways that some develop satisfying friendships despite social difficulties.

Methods:

We conducted semistructured interviews with 20 young adults on the autism spectrum about their lives after high school. Although interviews covered a broad range of topics related to transition, the subject of friendship came up frequently throughout the interviews. We extracted data specifically related to friendship for this article and used an inductive approach derived from grounded theory to identify and examine concepts.

Results:

Participants had the most success in relationships in which their atypical behavior was normalized. Specifically, this occurred among friends who accepted and appreciated their social differences and through common interests where these differences were not a concern. In other relationships, participants felt that they were expected to adhere to social norms, but found it uncomfortable and/or were not sure how to act in some contexts. Therefore, finding friends who did not expect this was a welcome relief. Participants who were socially isolated wanted more opportunities to meet other people, such as organized social groups, but were not sure how to access these.

Conclusion:

Results suggest that friendship, although challenging, can be navigated successfully for some young adults on the autism spectrum. These findings have implications for supporting young adults in their efforts to make friends in ways that work best for them and for creating measures that more accurately reflect their perspectives and needs. Reframing the concept of friendship to include a wider array of experiences and perspectives, identifying successful strategies, and creating more accurate assessments could present a very different picture of friendship and contribute to better outcomes for this unique population.

Lay Summary

Background:

Young adults on the autism spectrum often have difficulty making friends due to challenges with social communication. Nevertheless, some do enjoy friendships with their peers. The purpose of this article is to describe friendship seeking from the perspectives of young adults on the autism spectrum and explore the diverse ways that some develop satisfying friendships despite social difficulties. This information can be used to support young adults in their efforts to make friends by identifying the approaches and strategies that work best for them.

About This Study:

The information in this article comes from a study we conducted about the transition to adulthood for young adults. We interviewed 20 young adults about their life experiences in their late teens and 20s. Friendship was very important for most of them and they described their desires to have friends, their efforts to make friends, and the significant difficulties and frustrations they faced. They attributed these difficulties to being seen as different from others and too few opportunities to socialize. They had the most success by finding friends who accepted and appreciated their social differences. In these relationships, they did not have to worry about social norms the way they usually did. Several participants found it easier to relate to others on the spectrum and participated in organized social groups. Still others made friends around shared interests where their autism was not a primary concern. Overall, our interviews showed that young adults on the autism spectrum seek friends in a variety of ways.

What This Information Tells Us:

Researchers and service providers often conclude that friendship for people on the autism spectrum is lacking when compared with their typically developing peers. However, the experiences of some young adults can tell a story of difference rather than deficit. From this and other studies, it is clear that people on the autism spectrum may perceive friendship differently, have different priorities or goals for friendship, and have different ways of seeking and experiencing friendship than their typical peers. If we broaden our ideas of friendship to be more inclusive, things might appear very differently. Even so, many young adults struggle to make friends. By understanding their experiences with friendship, identifying where they need help, and identifying strategies and approaches that might work best for them, we can better support their efforts.

Introduction

Youth and adults on the autism spectrum often have trouble making and maintaining friendships due to the differences in social communication that are characteristic of autism spectrum disorder.^1–7 Research shows that the majority of these adolescents and young adults are socially isolated. Examining data from the National Longitudinal Transition Study-2,⁸ Shattuck et al.⁹ found that 43% of adolescents (ages 13–17 years) on the autism spectrum never got together with friends outside of school or organized activities. More than half (54%) never received phone calls from friends and only half (50%) were invited to social activities by friends. Similarly, Orsmond et al.¹⁰ examined peer relationships and participation in social and recreational activities and found that <30% had at least one close friend or a peer relationship that involved some shared activities. Almost half of the sample had no peer relationships at all outside of structured settings (such as school, work, or other arranged social groups). In three studies, older children and adolescents on the autism spectrum reported more loneliness and poorer friendship quality.^11–13 Social isolation may persist into adulthood.¹⁴ Indeed, Orsmond et al.¹⁰ found that adolescents were more likely to have peer relationships than adults. Lounds Taylor et al.¹⁵ found that autistic young adults had low levels of both structured and unstructured social activities during the transition to adulthood. Finally, few autistic adolescents and adults reported having friendships or romantic relationships.^16–18

These high rates of social isolation are troubling and the interaction between social challenges and isolation contributes to difficulties with friendship. Other research, however, suggests a different picture of friendship for youth and adults on the autism spectrum. In some studies, youths' perspectives about friendship differed from those of their parents and researchers. In Kuo et al.'s⁶ study of social activity during the summer, youth identified more friends than their parents did and described friends as those with common interests. By contrast, their parents thought of friendship as having mutual benefit and emotional connection. Carrington et al.³ found that youth with Asperger's syndrome did not see themselves as having problems with social skills, but their parents did. Several researchers measured the quality and characteristics of youths' friendships using standardized measures (e.g., Bukowski et al.'s Friendship Qualities Scale,¹⁹ Asher et al.'s Loneliness Scale²⁰) but noted that although youth on the autism spectrum fared poorly overall, they may have different perceptions of what constitutes friendship. For example, Locke et al.¹² conducted a social network analysis of an inclusive class and found that six out of seven youth on the autism spectrum identified “best” friendships with other youth on the autism spectrum. Although results showed that they had poorer social networks than their classmates, these youth formed clusters with each other and enjoyed some of the same protective factors as their better-connected typical peers. Researchers concluded that “friendship between adolescents on the autism spectrum may not be considered high in quality under the normative model of friendship, but may be appropriate for these adolescents with ASD and just as valuable in terms of overall development.”^{12(p. 79)} Carrington et al.³ suggested that a professional's concept of what is important in friendship may be different from that of youth on the autism spectrum, and that this should be taken into account when delivering services.

By its clinical definition, autism is characterized by “persistent deficits in social communication and social interaction” when compared with typically developing people.¹ Most researchers who study friendship among children on the autism spectrum have based their assessments on this model and frequently found these children lacking in their social abilities and pursuits. However, other researchers and advocates suggest that a broader conception of friendship could make room for different perspectives and experiences, rather than characterizing them as deficient. Brownlow et al.²¹ note that recent research demonstrates that people on the autism spectrum want and pursue friendships “but find the management of such relationships problematic at times or have alternative ways of performing or experiencing friendships” (p. 190).

The purpose of this article is to describe the perspectives of young adults on the autism spectrum about how they seek friendship. We present and discuss ways in which some have been successful in finding friends who accept and appreciate their social differences and/or develop friends through common interests where the characteristics of their autism are not a primary concern. Our findings suggest that current interventions and approaches fall short, in part, because they are not responsive to this population's differences, strengths, preferences, and support needs. Understanding friendship from their perspectives can inform better research, service delivery, and outcomes.

Methods

The data analyzed for this article was derived from a larger qualitative study about outcomes after high school for young adults on the autism spectrum²² that included young adults aged 18–29 (n = 20), parents (n = 21), and service professionals (n = 11). First, we describe the study, then focus on young adults' perspectives about friendship.

The purpose of this study was to understand how young adults and their supporters (parents and service providers) experience the transition to adulthood, including leaving high school, their experiences with adopting adult roles, goals for the future, and what kinds of support they need to help them achieve desired outcomes. We drew from the 2015 National Autism Indicators Report,²³ which examined national level survey data from several sources and demonstrated that transition age youth on the autism spectrum fare poorer than their peers in key outcome areas (e.g., employment, postsecondary education, and social and community participation). This information highlights the challenges and needs of this growing population; however, we are not sure what these outcomes may look like in the daily lives of young adults. To understand this, we examined how young adults and supporters think about outcomes for themselves, their children, and their clients. We asked what kinds of supports young adults needed to help them achieve their goals and what were the barriers and facilitators to achieving desired outcomes. For example, what role(s) would a person on the autism spectrum like to have in the community? What has been their experience using social support services? What additional help would be most effective in supporting their efforts to increase their social and community participation?

Study design

We used semistructured interviews, which allowed us to ask questions about the topical areas we were interested in, while giving a participant the opportunity to add information. We also tailored questions to the individual so that the interview best represented their perspectives. The first and second authors designed interview protocols for young adults and parents, which gathered information about a participant's daily life, their experiences with developing adult roles (i.e., employment, postsecondary education, living arrangements, and social participation), their goals, and support needs.^* We tested the protocol with a parent and young adult participant, reviewed the results, and adapted the questions. We found over time that participants' experiences and perspectives varied widely, so we used questions as a general guide. To ensure that we collected data thoroughly and consistently, we made sure to cover the major topical areas for each interview, even if we did not ask questions as they were written in the protocol. Drexel University's Institutional Review Board approved this study and participants received a $50 gift card for participating.

Recruitment

Participants lived in the Philadelphia, PA, metropolitan area in the United States. We recruited them through local channels such as online parent groups, advocacy organizations, service organizations, mental healthcare providers, and social media. We relied on self-reports of autism diagnosis, co-occurring conditions, and descriptions of impairments (e.g., executive functioning, challenges related to co-occurring conditions, and difficulties with social interaction). All participants were legally independent adults.

Data collection

The first author, a psychologist with expertise in qualitative methodology, or a research assistant, a master's level student, conducted interviews with young adults. Interviews took place in person at our office or in their homes (n = 10), by phone (n = 7), or by email (n = 3). We gave participants a choice about their preferred mode of communication, however, when an in-person meeting was not feasible due to travel or scheduling restrictions, we conducted the interview over the phone. In-person and phone interviews lasted ∼90 minutes. We recorded interviews and had them transcribed by a professional service. Of the three who completed the interview through email, at least one communicated primarily through typing. We did not ask about verbal communication abilities, but the other two participants' answers indicated that they did not have problems with verbal speech (i.e., they wrote about talking to their friends or coworkers). See Table 1 for demographic information about participants.

Table 1.

Participant Demographics, Autistic Adults (N = 20)

Demographic	n (%)
Age (years)	Mean 23.5 (range 18–29)
Gender
Male	11 (55)
Female	7 (35)
Gender nonbinary	2 (10)
Race/ethnicity
Non-Hispanic white	18 (90)
Asian	1 (5)
African American	1 (5)
Educational attainment
High school	20 (100)
Some college	5 (25)
Attending college	5 (25)
Bachelor's degree	4 (20)
Graduate degree	2 (10)
Living situation
Live independently	6
Live in parents' home	13
Supported community	1
Current employment
Yes	7 (35)
No	13 (65)

Data analysis

We analyzed data using an inductive approach derived from grounded theory that used a two-stage process of open coding and focused coding.^24,25 After reviewing several transcripts, the first and second authors derived a preliminary coding scheme based on (1) topics covered in the interview guide (i.e., employment and social participation), (2) topics that arose in interviews and applied to several participants (i.e., attending college), (3) concepts (i.e., independence), and (4) experiences (i.e., leaving high school and looking for a job). Then, they and a research assistant independently coded three transcripts using QSR NVivo 11 software and met to discuss results and refine the scheme. The first author and a research assistant coded the remaining transcripts and met regularly to review the findings and draw preliminary conclusions about concepts and themes related to the transition to adulthood. We developed second-level codes during the process of reviewing transcripts. For example, these included the concepts we present in this article, such as persistent efforts to make friends and attributing their difficulties to their atypical behaviors and perspectives. We examined the content of each code and took notes to interpret preliminary data and build a conceptual framework. At this point, the first author analyzed and interpreted the remaining data, discussing ideas with the second author regularly.

Although the focus of the study was about outcomes more broadly, the data we present in this article relate specifically to friendship. This topic came up throughout the interviews with young adults and warranted a closer look. To analyze data on this topic, we further analyzed data that we coded as “friendship” and “social relationships” to identify the themes and strategies presented here. Participants discussed their experiences with pursuing friendship, including successful and unsuccessful efforts to make friends, feeling discouraged about socializing and making friends, and describing the characteristics of friends they spent time with. Although we discuss only results from interviews with young adults here, we cross checked the data with parent interviews. They expressed similar concerns and described their children's interests in friendship, approaches to making friends, and the challenges they encountered.

Results

Participants had struggled to make friends during their school years and some continued to do so after high school. They identified ongoing challenges with social relationships and/or a lack of opportunities to socialize as the major barriers. They also described persistent efforts to make friends using a trial-and-error approach, some of which had paid off. Friendships stemmed from finding people who accepted their social differences, finding others on the autism spectrum, sharing identities other than being on the autism spectrum, and common interests where their autism was not necessarily a central concern.

Navigating social norms

Participants consistently said that social relationships were their greatest challenge. They felt pressured to adhere to social norms, such as everyday conversation, but found it uncomfortable and/or were not sure how to act in some contexts. However, not adhering to these norms often resulted in negative reactions from other people or social rejection. Despite the discomfort, modifying their behavior was an approach that most had or currently tried in developing social relationships, with varying success.

For one participant, putting normative social skills into everyday practice relied on observing peers' behaviors, identifying a role for himself in social situations, and persistence. For example, he sought out more talkative people, which relieved some of the pressure he felt to converse. He had also changed his approach to social situations through trial and error.

But you just can't… walk up to a group of people and just start talking with them and expect them to accept you… I've seen my mom do it and I don't know how she does it. Like she would sit next to somebody and you know, overhear something and start talking to them about it. I tried doing something like that, I got chewed out so many times. It's eavesdropping. [YA_01]

Over time, however, he developed the strategy of observing others' behaviors in a social situation before engaging in the conversation. Later in high school he was willing to take more risks and to experiment with approaches since he would be graduating soon.

So I just kind of like plop myself in a thing and just kind of watch and see…You know what? Even if I completely goof up—you know, I'm going to try, I'm going to put myself out there. Because in less than six months, I'm probably never going to see more than half these people again.

Although conforming to social norms was sometimes a way to connect, it was also a way to mitigate negative reactions. One participant described it as knowing what to say and do, but also being mindful of what not to say and do.

The first thing that pops into my head when I'm speaking to people could often be taken as offensive, crude, harsh, etc (all of these words have been used to describe me before I got better at filtering). It is tiring to do that all the time so I can't sustain too much interaction where I need to put on a socially-safe version of myself. [YA_21, email interview]

Another woman described a stark contrast between the social support and friendship she had found at her college and her current experiences in graduate school. The college she attended had an extensive autism support program where she felt accepted and understood, but at graduate school she felt excluded from her fellow students.

I watch them interacting with each other, they are all laughing, and telling jokes with each other, and sharing stories, and Facebook stuff. Goofing around, and they are just… relaxed with each other. With me, nobody talks to me that way. [YA_11]

Other participants told similar stories but some had found friends who accepted their social differences and/or who shared interests. We describe these themes below.

Finding friends who accept their differences

Social differences were typically the reason participants had trouble making friends and feeling accepted. Therefore, finding friends who accepted these traits was a primary goal. Finding people they felt comfortable with meant that they did not need to adhere to social norms as they did in more shallow relationships, such as with acquaintances. With their friends, their autism was not a deficit but a difference that was normalized by finding a place where they fit in. One young woman described her relationships with her boyfriend and best friend as different than other peers because “they weren't offput by how I am naturally when I didn't have a filter on. Other people tend to recoil if I'm not careful” [YA_21, email interview]. Others found that their experiences or outlooks provided common ground for friendships and that challenges posed by autism were less of a concern. For example, one man described his friends as “unique” and said, “… the people that I normally relate to are usually like people that try to be very different from the crowd…” [YA_08]. For him, autism fits into his concept of uniqueness. Another participant, who identified as gender nonbinary felt connected to a community of queer and transgendered people who were broadly accepting of mental health issues and other disabilities.

About half of the participants said they found it easier to relate to other people on the spectrum because of shared understanding and experiences.

When I am around other people on the spectrum [we] seem to understand each other. We are all friendly with each other. It is no judgment. I always feel like when I am around people who do not have autism that I am missing part of the language like system… it is like being on the wrong frequency with them whereas when I am around other autistics, we are on the same frequency. [YA_11]

Similarly, another participant described that “just ‘hanging out’ for people on the spectrum is really just being in the same room and occasionally saying something” [YA_03].

Organized social groups with other people on the autism spectrum played a regular role in some participants' social lives. One young woman [YA_04] had a difficult time making friends after college, primarily because she lived in the suburbs, did not drive, and had limited access to public transportation. So, she formed a social group and organized regular events. Although all members could participate independently, the group was otherwise diverse, ranging in age, abilities, and autism characteristics. Others joined pre-existing groups or social programs that were also broadly inclusive.

For many of these young adults, finding a niche in which they felt comfortable being themselves was a welcome change to how they experienced other social contexts and relationships. Although some found it easier to relate to other people who were on the autism spectrum, others felt accepted by friends who were not on the spectrum but who liked their atypical personalities. And for some, autism was folded into their friendships that were characterized by a shared outlook or experience.

Shared interests

Shared interests were another gateway to friendship. Because these relationships focused on an activity or topic, their social differences were not necessarily a central concern, whereas in every day interactions, these differences stood out. For one young woman whose main interests were video gaming and cosplay (i.e., dressing as characters from video games and comic books and attending conventions), these particular interests served as an entry point to conversation and ongoing connection. She described:

I can only make friends when I am cosplaying, when I dressed up as an anime or a manga character and interact with other people who do that too. They are the ones who approach me, usually. The only way I will approach somebody, if there are dressed up as a character I like, then I will approach them and ask to take a picture of them and stuff like that. I really have a hard time approaching other people. [YA_02]

She also made friends through online gaming and a related Facebook group. She considered these as friendships, even though she had never met or spoken to most of the members. She had two friends she saw in person and found the combination of these friendships fulfilling. In fact, she said that she did not want more than a few friends because she would find it stressful. Others found friendship through their interests in the creative arts, such as one young woman who spent a lot of time drawing and shared these drawings with her best friend through a website. In this case, her friend was also on the autism spectrum but the focus was on their art and video chatting with each other.

Discussion

Consistent with other research,^2,4,5,7,26 we found that young adults on the autism spectrum desired and sought friendships but that social differences often made it more difficult to develop and maintain these relationships. Participants described their desires to have friends, their efforts to make friends, and the challenges and frustrations they encountered, either in the past or present. Practicing normative social skills was necessary for navigating the social world. These sometimes helped them connect to others and, when necessary, mitigated negative reactions from others. They had the most success by finding people who accepted their atypical social behavior, often relieving them of the pressure they felt to adhere to conventional social norms. For some, organized social groups with other people on the autism spectrum were a regular part of their social lives. Still others made friends around shared interests where their autism was not a primary concern.

Most people, autistic or not, seek friends who accept them and who share interests. For young adults on the spectrum, however, these relationships can be harder to develop because their social differences often set them apart. Participants described not understanding social rules in various contexts, such as in everyday conversation, or not wanting to adhere social norms because it took a lot of effort and felt uncomfortable. As a result, they found it difficult to relate to other people, especially those who were not on the spectrum. They described years of persistent efforts to make friends, taking a trial-and-error approach to engaging with others and developing connections, and setbacks as well as successes. Friends who accepted their atypical social behaviors also seemed to appreciate these characteristics, such as the young man with “unique” friends or those who felt a mutual understanding with others on the spectrum. Specific shared interests, such as art or videogames, were a pathway to friendship. In these cases, the characteristics of their autism that were problematic in other relationships were less of a concern. Of course, the themes we discussed here may overlap and vary between contexts. In some settings, identifying as being on the spectrum may be important, such as being part of a social group. In others, it may not be relevant to a common interest or activity. The social quirks that others appreciate or extensive knowledge about a particular topic may be strengths. Overall, the picture that emerged from interviews highlighted diversity in friendship-seeking experiences for young adults on the autism spectrum. These findings suggests that a broader, more inclusive conception of friendship for people on the spectrum can reframe social differences as exactly that—differences that are not deficient.

This study has implications for supporting young adults in their efforts to develop social relationships through interventions. Similar to our findings, several researchers have suggested that shared interests can play an important role in cultivating friendships and creating safe social spaces for young people on the autism spectrum.^5,27,28 Orsmond et al.¹⁰ recommended that resources be directed to organizations and groups that support social inclusion. Unfortunately, current efforts to facilitate peer relationships fall short. Participants who lacked satisfying friendships wished for social opportunities or supports but did not know where to find them. Some were disappointed in programs and workshops that were a mismatch with what they needed (e.g., a workshop on dating was too basic when they wanted to learn how to flirt). Formal social skills training may be insufficient to give young adults the tools they need to navigate everyday social interactions. Such interventions tend to focus on impression management, adhering to social norms, and rehearsing social interactions.^29,30 For adolescents and young adults, interventions typically take place in a clinical setting and are administered by a service provider rather than in a naturalistic setting that includes typically developing peers.³⁰ Also, interventions emphasize individual behavior modification in social situations, but not cultural change that could be more inclusive of individuals on the autism spectrum. Sasson et al.³¹ note that opportunities for individuals on the autism spectrum to practice social skills are impaired when their typically developing peers are reluctant to socialize with them. They suggest that intervention and education efforts take a more holistic approach and target both groups.

By understanding young adults' views on friendship and the specific challenges they run into, we can identify effective approaches and better support their efforts. For example, adults on the autism spectrum who were interviewed by Müller et al.⁷ recommended strategies for improving and increasing social opportunities that included external supports, such as activities based on shared interests, structured or scripted activities, and socializing in small groups or dyads. In our study, organized social groups that were broadly inclusive of people on the autism spectrum and other disabilities played an important role in some young adults' social lives. Other participants wanted access to social groups but did not know where to find them, which demonstrates a need for more groups and outreach efforts. Such opportunities may be particularly significant for those whose disabilities may further limit their involvement in the community. For example, one young man whose anxiety, depression, and gastrointestinal problems often prevented him from leaving the house did not have peer friendships, although he wished it were different. Another young man who had significant difficulties with speech and movement and communicated through typing described, “I do have friends and relationships with my family like the typical person but nothing is easy” [YA_14]. He took college courses both online and in person and participated in a social group, but support from family, friends, and services was key to facilitating these activities. Notably, some of the successful approaches participants described were self-initiated rather than delivered as a service. This suggests that young adults can also be supported in more informal ways. For example, guiding them to seek friends who are understanding and appreciative, rather than practicing social norms that mask their autism characteristics or encouraging other venues or forms of friendships, such as online communities.

Finally, these findings have implications for how researchers and practitioners characterize and assess social relationships. Most standard data collection tools operationalize measures using a normative framework, such as questionnaires that record frequency of contact, social network analyses that measure connections, and surveys that ask about communication and activities. These are important indicators of social activity and highlight areas of concern, but they may not fully capture subjective information, such as what is important to a young adult in terms of friendship and how they prefer to socialize. Understanding how their everyday experiences may not match up with normative frameworks presents an opportunity to design measures that reflect their priorities. Our findings about young adults' experiences, perceptions, and approaches to friendship-seeking suggest that subjective indicators might offer a different picture of social relationships for this group and provide guidance on how services and interventions can be responsive to their needs.

Overall, findings from this study suggest that friendship, although challenging, can be navigated successfully for some young adults on the autism spectrum. We did not directly examine how the experiences of friendship-seeking for young adults on the autism spectrum compare with those of their typically developing peers. Some of their preferences, such as wanting only a few friends, taking time to find friends, and feeling accepted for who they are, could be said for many people. However, it was clear that participants felt that their autism set them apart and that they had a harder time making friends. Young people on the autism spectrum may perceive friendship differently, have different priorities or goals for friendship, and have qualitatively different ways of seeking and experiencing friendship than their typical peers. Therefore, approaches that are not responsive to their needs may be less effective.

Limitations and strengths

As a small qualitative study, findings are limited to this group, who were fairly homogeneous (mostly white, all with at least a high school education, and capable of participating independently in a lengthy interview). However, the ideas and concepts we discuss here are consistent with other research about social challenges and motivations for people on the autism spectrum. In addition, we present an alternative view to mainstream assumptions about friendship and we suggest that a broader, more inclusive understanding could have profound effects on how researchers assess friendship for young adults on the autism spectrum, how providers deliver services, and how the community at large can best support their efforts to make friends.

Another limitation is that because friendship was not the focus of the larger project these data were taken from, we may have missed some important perspectives and topics. For example, few discussed using social media to make or connect with friends, as might be expected for this age demographic. Nevertheless, our study makes important points about how young adults pursue and experience friendship.

Conclusion

By its clinical definition—persistent difficulties in social communication and social interaction and restricted, repetitive patterns of behavior, interests, or activities¹—autism is characterized as a disorder to be treated using mainstream standards of behavior. However, young adults' experiences can tell a story of difference rather than deficit. A more inclusive conception of friendship and better understanding of the perspectives, priorities, and needs of this heterogeneous population can have major implications for supporting young adults to develop friendships in ways that work for them.

Authorship Confirmation Statement

Drs. Sosnowy, Silverman, and Shattuck conceived the study. Drs. Sosnowy and Silverman designed protocols for data collection. Dr. Sosnowy collected data and oversaw research assistants who participated in collecting data. Drs. Sosnowy and Silverman designed the data analysis protocol (i.e., coding scheme) and coded three transcripts to test and refine the coding scheme. Dr. Sosnowy and research assistants coded the remaining transcripts. Dr. Sosnowy interpreted the data, consulting with Dr. Silverman regularly. Dr. Sosnowy drafted this article with input on revisions from Drs. Silverman and Shattuck. Ms. Garfield conducted background research and contributed to the discussion section. All coauthors have reviewed and approved of the article before submission. This article has been submitted solely to this journal and is not published, in press, or submitted elsewhere.

Author Disclosure Statement

No competing financial interests exist.