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Autism in Adulthood: Challenges and Management logoLink to Autism in Adulthood: Challenges and Management
. 2021 Sep 2;3(3):230–237. doi: 10.1089/aut.2020.0034

Cultivating Self-Compassion to Improve Mental Health in Autistic Adults

Ru Ying Cai 1,2,✉, Lydia Brown 3,4,5
PMCID: PMC8992903  PMID: 36605368

Abstract

Many autistic adults experience poor mental health. Research has consistently shown that cultivating self-compassion is a promising approach to strengthening resilience in nonautistic adults. Self-compassion is a trainable skill that is associated with several mental health benefits, such as higher levels of happiness and well-being as well as lower symptoms of depression and anxiety. However, no studies to date have explored self-compassion in autistic individuals. We suggest that self-compassion may be a relevant target in mental health interventions for autistic adults without severe or profound intellectual disability. Self-compassion may improve mental health in autistic adults through directly modifying emotions (as an emotion regulation strategy) or its interactions with emotion regulation processes. Existing approaches to cultivating self-compassion include identifying and practicing self-compassionate behaviors, using self-compassionate thought records, and practicing self-compassion meditations. Before self-compassion approaches are implemented by autistic adults, it will be necessary to evaluate their role and effectiveness in mental health through carefully designed studies. We suggest that researchers should first study the relationship between self-compassion and mental health outcomes in autistic adults. Once researchers have established the connection, we can then begin to study self-compassion-based interventions for autistic adults. Relevant clinical considerations include identifying the autistic groups that self-compassion practices are suitable for, determining how autistic adults with and without mental health conditions can effectively practice self-compassion (on their own and with the support of clinicians), and evaluating existing self-compassion tools or designing new tools. It is also relevant for future research to identify the enablers and barriers to using self-compassion in autistic adults.

Lay summary

What is self-compassion?

Self-compassion is when we:

  • are friendly toward ourselves (kindness)

  • are aware of our feelings and thoughts (mindful awareness)

  • realize that everyone feels pain and makes mistakes (common humanity)

What is the purpose of this article?

We think that practicing self-compassion is important for autistic adults. No research has studied self-compassion in autistic individuals. We provide examples of how to improve self-compassion. We make recommendations for future research on self-compassion for autistic adults.

What perspectives do the authors bring to this subject?

We bring together different and unique perspectives in this article. One author is a researcher whose research has focused on emotion regulation and mental health in autistic youth and adults. The other author is a self-compassion researcher who is also a private practice clinical psychologist. We have practiced self-compassion and personally experienced the benefits of developing our self-compassion skills. We think that cultivating self-compassion has helped to improve our mental health and enriched our lives.

Why is self-compassion important?

Self-compassion is associated with a lot of positive aspects of life in nonautistic individuals. These positive aspects include greater happiness and well-being, and lower levels of depression and anxiety symptoms.

How is self-compassion relevant to autistic adults?

We know that as a group, autistic adults have poorer mental health when compared with nonautistic adults. That is, autistic adults experience higher rates of anxiety and depression. Research shows that practicing self-compassion in nonautistic people can improve their mental health. We think that cultivating self-compassion can also be helpful to autistic adults.

What do the authors recommend?

We suggest that cultivating self-compassion may improve the mental health of autistic adults. There are several ways to improve self-compassion. Self-compassion can be improved by identifying and practicing self-compassionate behaviors. For example, we can take a walk outside. Another way to improve self-compassion is to record our thoughts. This can be performed by keeping a log of self-critical thoughts. We can also practice self-compassion by meditating. It is too early to tell how self-compassion should be practiced by autistic adults. Research is needed to observe if self-compassion is helpful to autistic adults. We made a series of recommendations for researchers and clinicians. Researchers should first check if there is a relationship between self-compassion and mental health in autistic adults. If more self-compassion is associated with better mental health, then researchers and clinicians can try and find out how we can improve autistic people's self-compassion.

How will these recommendations help autistic adults now or in the future?

We hope that our recommendations will start a conversation on the relevance of self-compassion for autistic adults and lead to the development of self-compassion-related research programs that involve autistic adults. The ultimate goal is to improve the mental health and psychological well-being of autistic adults in the future.

Keywords: self-compassion, autism, adults, mental health, emotion regulation

Introduction

“The time will come

when, with elation

you will greet yourself arriving

at your own door, in your own mirror

and each will smile at the other's welcome,

…

You will love again the stranger who was yourself.”1

Love after love by Sir Derek Alton Walcott

A large proportion of autistic adults experience mental health conditions.2 Although mental health interventions are useful for a portion of autistic adults, not all autistic adults have access to adequate mental health services.3 Importantly, there is wide variability in autistic people's responses to treatment.4 Thus, researchers are examining the efficacy of new approaches to help improve the mental health of autistic individuals.5 In nonautistic samples, reduced levels of self-compassion are associated with increased psychopathology.6 Research findings have also shown that cultivating self-compassion is an approach for improving nonautistic people's mental health and psychological well-being.7 In this Perspectives piece, we suggest that the cultivation of self-compassion may be an effective complementary approach to support the mental health of autistic adults, even though there is currently no self-compassion research in autism.

The authors bring together different and unique perspectives in this article. Dr. Cai is a postdoctoral researcher at an autism research center whose research has focused on emotion regulation and mental health in autistic youth and adults. Dr. Brown is a private practice clinical psychologist and self-compassion researcher who has an interest in understanding the clinical utility of self-compassion-based interventions. Through our own contemplative practices, we have come to appreciate the importance of cultivating self-compassion to improve our mental health and enrich our lives. We hope that this Perspective article will help introduce the concept of self-compassion to the autistic and autism community. We aim to: (1) provide a summary of mental health research in autistic adults; (2) highlight the reasons why we think self-compassion is relevant for autistic adults, especially those with mental health conditions; (3) describe examples of exercises that can improve self-compassion; and (4) provide a series of recommendations for researchers and clinicians.

Mental Health of Autistic Adults

Mental health conditions are highly prevalent in autistic individuals. Two of the most common mental health conditions experienced by autistic individuals across the life span are anxiety and depression, with reported frequencies of anxiety up to 84% and depression up to 70%.2,8–13 A systematic review of depression rates in autistic adults without intellectual disability (ID) showed rates varied between 1% and 47%.14 The authors also concluded that depression rates of autistic adults in most studies were higher than those of general population (up to 10.7% depending on the study). The large variations in the rates reported for both conditions across studies may be the result of factors such as intellectual ability and other methodological issues including measures not being anxiety- or depression-specific, measures not being suited to autistic people, relatively small sample sizes, and recruitment via clinical services.14

Mental health conditions have a significant negative impact on autistic adults. For example, depression has negative consequences on quality of life, including increased maladaptive behaviors, loss of interest in activities, appetite and sleep problems, and decreased adaptive functioning,15 as well as suicidal ideation.16,17 Suicidality among autistic individuals is a prevalent and concerning issue. Two recent systematic reviews found that suicidality was present in 11%–66% of autistic samples,18,19 rates that are substantially higher than those found in the general population. The mortality rate by suicide is also higher for autistic individuals when compared with the general population controls matched on gender and age (0.31% vs. 0.04%).20 Having a mental health condition is one of the risk factors of suicidality in autism.18 Given that the National Strategy for Suicide Prevention recommends that treatment for individuals at high risk of suicide should include the identification and treatment of mental health conditions,21 it is likely that treatment of mental health conditions would also reduce the risk of suicide for autistic adults.

Current mental health treatments such as cognitive behavioral therapy (CBT) and mindfulness-based therapy (MBT) seem to be effective for autistic adults. Much of the CBT research in autism has focused on children and adolescents (see reviews by Ung et al.22 and Vasa et al.23). A narrative review found that CBT is moderately effective for treating anxiety and depression for autistic adults24; however, limited sample sizes, varied clinical characterization of participant, and suitability of self-reported questionnaires used to measure treatment outcomes for autistic individuals were highlighted as significant limitations. There is only a handful of studies examining the efficacy of MBT for autistic adults. Hartley et al. conducted a meta-analysis of MBT for autistic children, autistic adults, and caregivers.25 They found that autistic adults reported small to large improvements in subjective well-being (including symptoms of anxiety and depression, and rumination) postintervention and at follow-up. More recently, a systematic review by Benevides et al. identified CBT and MBT as the approaches considered to have emerging evidence for reducing psychopathology in autistic adults without ID.26

Although there is emerging evidence that mental health interventions such as CBT and MBT are effective for autistic adults, not all adults have access to adequate mental health services.3 For example, many autistic adults do not receive CBT.27 This observation has prompted researchers to begin investigating the factors that influence the use of CBT among autistic adults.28 Furthermore, treatments are not effective for everyone.4 Camm-Crosbie et al. surveyed 200 autistic adults without ID about their experiences of treatment and support for mental health problems, self-injury, and suicidality.4 Almost 20% of participants felt that their mental health issues were not appropriately treated. A similar proportion of participants thought that treatments and support provided were not fit for purpose (e.g., when an autistic client interpreted communications from clinician literally, clinician thought that this client had a defense mechanism). In addition, 11% of participants thought that CBT was not an effective treatment for them. This poor access to adequate and suitable mental health services has prompted researchers to examine the efficacy of different models of treatment delivery and new approaches to help improve the mental health of autistic individuals. Gaigg et al. examined the efficacy of self-guided online tools that delivered CBT and MBT using a waitlist-controlled trial.5 The researchers found that anxiety levels of autistic adults in active conditions significantly decreased and were maintained for 3 months. Therefore, the researchers concluded that online CBT and MBT tools are cost-effective to deliver mental health treatment and support to autistic adults who prefer engaging with online platforms.

Some people have criticized the traditional approach to mental health care. Van Os et al. argued that mental health disorders should be framed as vulnerabilities and that psychological well-being can be improved through supporting people to live with their mental vulnerabilities through strengthening resilience in the existential and social domains.29 Rather than aiming to reduce symptoms alone, the focus should be on aspects such as increasing positive emotions and acceptance, building connections with others, and developing a sense of purpose. One approach to strengthen resilience is to foster self-compassion skills.

Self-Compassion Research in Nonautistic Populations

Self-compassion is a healthy way of relating to the self that is based on kindness rather than self-criticism; mindful awareness rather than overidentification with negative emotions; and common humanity as opposed to isolation.30 Self-compassion becomes salient during moments of perceived failure or general suffering and shapes how an individual responds to these difficulties. For instance, if a supermarket manager gives an employee negative feedback about how they handled a difficult customer, someone low on self-compassion might think to themselves “I am so hopeless, I am always terrible with customers, and I will probably get sacked.” However, someone higher on self-compassion might respond to the negative feedback more adaptively. They might take a moment to calm down and ground their awareness in the body (i.e., mindfulness) and use more self-reassuring language toward themselves by thinking something like “It's ok, everybody makes mistakes from time to time (i.e., common humanity), may I be kind to myself (i.e., self-kindness).” Compared with self-criticism, self-compassionate responses such as this have been found to reduce activation of neural networks associated with threat, including reduced activation of the amygdala and anterior cingulate.31 Self-compassion has also been shown to positively predict resilience.32,33

Self-compassion is related to the construct of mindfulness, but unlike mindfulness, self-compassion specifically relates to how individuals respond to moments of suffering and perceived failure.34 Self-compassion is also broader in scope than mindfulness, in that it involves the subcomponents of self-kindness and common humanity, which may be especially relevant as a means of downregulating negative affect during moments of stress.34 Due to the specificity of self-compassion to moments of distress and suffering, it has been reported that when compared with mindfulness, self-compassion may be a stronger predictor of well-being in clinical settings, such as those seeking help for anxiety.35

Being self-compassionate is associated with a host of mental health benefits, including lower symptoms of depression, anxiety, and stress and higher levels of happiness and well-being.6,34 People with mental health conditions such as social anxiety disorder, depressive disorders, and substance abuse have lower levels of self-compassion.35–37 Additionally, lower self-compassion in clinical settings is associated with poorer outcomes as well as maladaptive coping skills such as avoidance.36,38–40 Importantly, randomized controlled trials conducted in both clinical and nonclinical settings have found that self-compassion is a skill that can be enhanced through training.7 Interestingly, a study in parents of autistic children found that self-compassion predicted parental well-being over and above the effects of child autism symptom severity.41 However, there is not yet any consideration of the applicability of self-compassion to autistic individuals.

Self-Compassion as a Relevant Intervention Target for Autistic Individuals

Based on research in nonautistic samples reviewed above, it is plausible that self-compassion might be a beneficial psychological resilience factor among autistic adults, including those with mild or moderate ID. But to the best of our knowledge, self-compassion has neither been considered nor investigated empirically in the autism context. We propose that self-compassion facilitates mental health and psychological well-being in autistic adults by reducing the risk and severity of co-occurring psychological conditions that are common in this population. There are a few reasons why we think self-compassion might be an effective mental health intervention target in autism. First, MBTs have been shown to improve mental health in autistic individuals.42 Mindfulness is one of the three components of self-compassion, involving the capacity to pay attention to the present moment purposefully and nonjudgmentally, as opposed to identifying with thoughts and concepts about the past and future. Self-compassion is an extension of mindfulness in that it also entails the explicit idea of relating to suffering with kindness and compassion. This added step of relating toward suffering with kindness may have the additional advantage of downregulating negative affect, which may have benefits for mental health.

Second, given the limited access to adequate and suitable mental health services as discussed above, cultivating self-compassion skills through self-guided exercises and meditation may be an effective complementary approach to support the mental health of autistic individuals. Although there is currently no research on self-compassion in autism, there is evidence for the efficacy of self-compassion training for individuals with ID. Idusohan-Moizer et al. examined the efficacy of a 10-session mindfulness-based intervention for improving the mental health of nonautistic adults with borderline, mild, or moderate ID who had experienced one or more episodes of depression or generalized anxiety that incorporates a self-compassion session.43 During this session, participants learned how to self-soothe and respond to self-critical inner voices with kindness, as well as fostering positive self-affirmation and self-regard. Home assignments were given to participants during the self-compassion session to help participants respond to real-life situations with compassion and kindness. Results indicate that participants' self-compassion scores, as measured via the Self-Compassion Scale,30 significantly increased postintervention.

Two mechanisms by which self-compassion may reduce psychopathology in autistic individuals are directly modifying emotions (emotion regulation) or through its interactions with emotion regulation processes.44,45 We will now discuss the theoretical evidence for these hypotheses and their implications in autism.

Self-Compassion and Emotion Regulation

Emotion regulation is a process that involves the monitoring and modification of emotional responses that are goal-directed.46 It aims to modify the intensity, duration, and types of emotions experienced.47 Emotion regulation can also be automatic and outside of one's consciousness.48 Emotion dysregulation occurs when emotions are inappropriately and ineffectively regulated and may manifest itself in negative affectivity or irritability. Long-term emotion dysregulation is a transdiagnostic risk factor for mental health conditions in the general and autistic populations.49–51 Researchers have suggested that poor emotion regulation may be inherent in autistic individuals.52,53 Dr. Cai found that autistic children and adults use more emotion regulation strategies that are associated with higher psychopathology (maladaptive strategies).50 She also identified several emotion regulation strategies that predict momentary mood using experience sampling methodology in a sample of autistic and nonautistic adults.54 Specifically, strategies such as savoring and emotional acceptance improved mood, whereas strategies such as dampening and other-blame reduced mood. One of the factors that have been suggested to contribute to poorer emotion regulation in autism is alexithymia, which has been found to be more prevalent in autistic individuals than in nonautistic individuals.55

Berking and Whitley proposed that self-compassion is an adaptive emotion regulation skill in their Adaptive Coping with Emotions Model (nonautism-specific model).56 The model suggests that applying adaptive emotion regulation skills and strategies may lead to short-term mood deterioration, hence being able to provide effective self-support (such as self-compassion) is critical to stabilizing one's mood during the emotion regulation process. Indeed, there is growing evidence showing self-compassion to be an effective strategy to improve mood in clinically depressed individuals—self-compassion was even more effective than emotion regulation strategies such as reappraisal and acceptance,44,57 which are well established and known to be adaptive.51,58 Self-compassion was also positively associated with high heart rate variability (HRV) in a sample of university students.59 HRV is a physiological indicator of the capacity to regulate emotions60,61 because high resting HRV is associated with better emotion regulation and coping in both autistic and nonautistic adults.62–64 Given these findings, it is likely that improving self-compassion in autistic individuals, especially those with elevated levels of depressive symptoms, will likely improve their mood as well as their HRV.

Other than the proposition that self-compassion is an emotion regulation strategy, there is also preliminary evidence for a relationship between self-compassion and emotion regulation as two separate constructs. A recent systematic review identified five studies that examined the interactions between self-compassion and emotion regulation and found the two to be strongly correlated in nonautistic samples.45 Some of these studies suggested that emotion regulation mediates the relationships of self-compassion with stress,65 depression,66 and symptom severity of post-traumatic stress disorder.67 If a similar connection between emotion regulation and self-compassion is found in autism, targeting self-compassion may improve mental health in autistic individuals since consistent research evidence indicate that many autistic individuals have emotion dysregulation.

Approaches to Cultivating Self-Compassion

In previous work, Dr. Brown has described how self-compassion can be cultivated via two approaches: (1) self-compassion-based practices that can be used in everyday life and (2) self-compassion-based meditation practice.68 Through Dr. Brown's clinical practice working with a range of clinical populations, she has found that self-compassion-based exercises can be beneficial to support emotion regulation and overall well-being. She will now briefly provide specific examples as to how self-compassion can be trained. It is important to note, however, that self-compassion-based training has not yet been empirically tested or tailored specifically for use with autistic adults. Thus, these are general examples as to how self-compassion can be developed. Further clinical and experimental work is needed to apply these concepts specifically to autistic adults.

Informal self-compassion-based practices typically involve cultivating self-compassionate behaviors and self-compassionate thoughts. A foundational question of self-compassion is “What do I need right now?” In her clinical practice, Dr. Brown often asks her clients to use this question in moments when they are feeling distressed. It is important to differentiate needs from wants. In a moment of distress, a particular client might want to drink heavily to dampen negative emotions, but they actually might need support from a friend/family member, self-reassurance (e.g., a mantra such as “this is a tough moment, it will pass, may I be kind to myself”), or a change of physical environment such as a walk outside. It can be helpful to work with clients to brainstorm a list of “self-compassionate behaviors,” which is written down and can be placed in a prominent position such as on the client's fridge. The client is then instructed to choose an activity from the list when they are feeling distressed. A list of self-compassionate behaviors can be paired with a reward system to reinforce the habit of self-compassion in daily life. For instance, some people choose to keep a log of when they use their list, marked by points or stars, as a means to track the formation of the self-compassion habit. Unfortunately, to the best of our knowledge, a self-compassion-based smartphone app is not yet available, but we warmly welcome its development—as it could be a powerful visual resource to support individuals, including autistic individuals, in using self-compassion in daily life. Previous findings have shown the usefulness of visual and technological aids for autistic individuals in various contexts.69,70

A second powerful self-compassion-based exercise, related to CBT, is self-compassionate thought records. This exercise involves keeping a log of self-critical thoughts, together with details of the environmental triggers to these thoughts. Sometimes, the mere act of recording self-critical thoughts can be quite confronting—as people start to become more aware of how critical they can be toward themselves. Thus, it is important to normalize the inner critic and ask people to not judge themselves for being self-critical, but rather approach the exercise with nonjudgmental curiosity. Crucially, to help facilitate cognitive change, people are then asked to consider alternative self-compassionate thoughts that might be more reassuring during moments of stress. Documenting this on a thought record sheet (see template)71 can be helpful. Sometimes, people need help to think about self-compassionate language—thus engaging a trained therapist with knowledge and skills in self-compassion can be helpful to facilitate this process.

Other than the self-compassion-based exercises already described, regular meditation is another approach to increase self-compassion.72 Dr. Neff, the pioneering researcher of self-compassion, provides free, guided self-compassion meditations on her website.73 In the Self-Compassion/Loving-Kindness Meditation audio, Dr. Neff first grounds the listener by engaging bodily and auditory sensations and then asks the listener to bring to mind a negative aspect of their personality (e.g., failure or mistake) and get in touch with the unpleasant emotions (e.g., frightened, isolated) and associated bodily sensations (e.g., heaviness in heart, tension in shoulders). Dr. Neff then asks the listener to accept the emotions and sensations, acknowledge the suffering caused by the self-judgment, normalize the unpleasant emotions felt, and comfort oneself through repeatedly, nonverbal self-affirmations: “May I be safe; May I be peaceful; May I be kind to myself; May I accept myself as I am.” After a while, Dr. Neff asks the listener to consider others who experience similar unpleasant emotions and repeatedly affirm other people's need for safety and acceptance. Finally, the meditation ends with the previous self-affirmations.

Recommendations

We have provided general examples of exercises to improve self-compassion and develop self-compassion skills. We want to emphasize that the cultivation of self-compassion in autistic adults must be carried out with caution and informed by empirical evidence. Although the sample approaches outlined above are well established in a range of clinical and nonclinical populations, they have not been evaluated in autism, and dedicated empirical work is needed before these approaches are used by autistic adults. We would like to provide a few suggestions for future research.

As a first step, research should determine whether or not self-compassion is a significant predictor of psychological well-being outcomes among autistic adults without severe or profound ID. If evidence is found for the relationship between self-compassion and mental health, experimental research is needed to investigate the potential benefits of self-compassion-based interventions in this population. It is essential to understand which groups of autistic adults self-compassion practices are appropriate for. The cultivation of self-compassion in autistic people with relatively good mental health may improve their abilities to regulate emotions and prevent against future mental health issues. It is critical for us to understand how self-compassion can be effectively cultivated in autistic adults, especially those with mental health conditions. Even though we are advocates of self-compassion practices, we currently do not have enough information to make clinical recommendations due to lack of evidence. Researchers and clinicians must take care when introducing self-compassion practices to the autistic communities. We hypothesize that self-compassion practices can be self-directed and implemented without the assistance of mental health providers for some autistic individuals but not others with trauma histories or unstable mental health due to the possibility of practices triggering extremely negative emotions. For example, while self-compassion-based meditations can be a powerful gateway to increasing skills in self-compassion, they can sometimes be triggering—especially for those who are psychologically vulnerable (have a trauma history or unstable mental health).74 Thus, support from a trained therapist may be helpful to facilitate training in self-compassion-based meditation for some autistic individuals. It is also relevant to determine if self-compassion practices can be performed alone as well as in conjunction with other therapies for autistic adults.

Another relevant consideration is to identify the enablers and barriers to using self-compassion in autistic adults, including both individual and environmental factors. A possible individual-specific barrier already mentioned is intellectual functioning—currently, there is no evidence for the suitability of self-compassion practices for people with severe or profound ID. A potential environmental factor is the quality of relationships the autistic people have with others they interact with on a regular basis. For instance, if an autistic adult lives at home with helpful and caring parents, he/she/they could ask parents for emotional support during stressful moments, which is a healthy and self-compassionate behavior.

In summary, there is robust evidence from nonautistic samples to suggest that self-compassion may be relevant to the mental health of autistic individuals, but empirical research in this area is lacking. Since autistic adults often experience co-occurring mental health conditions and are at risk of having low psychological well-being, there is an urgent need to consider modifiable predictors of mental health in this population.

Authorship Confirmation Statement

R.Y.C. conceived the original idea for the article. R.Y.C. and L.B. drafted and edited the article. Both the authors have reviewed and approved the article before submission. The 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.

Funding Information

No funding was received for this article.

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