Relationship-counselling Recommendations for Partnerships Involving Autistic Adults: A Scoping Review

In recent decades there has been a marked increase in the diagnosis rates of autism spectrum disorder (henceforth “autism”; Australian Institute of Health and Welfare, 2017; Kring et al., 2016; Maenner et al., 2023). This increase has been seen not only in children but also in adults previously undiagnosed for such reasons as lack of diagnostic accuracy when they were younger (Kring et al., 2016), unawareness by practitioners of the variable presentation of autism (Magiati et al., 2014), the misdiagnosis of women (Bargiela et al., 2016; Bullen & Qadar, 2021; Russell, 2021), and exclusion of individuals from earlier DSM autism definitions, but who now meet the criteria (Meng-Chuan & Baron-Cohen, 2015).

Autism is a lifelong condition that currently presents in an estimated 1-4% of the population (AIHW, 2017; Maenner et al., 2023). As defined in the current DSM-5-TR by the American Psychiatric Association (APA, 2022), autistic individuals^[1] experience persistent difficulties with both verbal and non-verbal social interactions and communication. They have difficulty in social settings when reciprocity is expected and are challenged with the nuances of personal relationships (APA, 2022). Other characteristics are also evident, such as stereotyped and repetitive movements, speech, or object use; resistance to change and excessive reliance on routines and rituals; highly focused and fixated interests; and intense or minimal rather than moderated reactions to sounds, lights, and smells (APA, 2022). Onset happens in early childhood, but indicators may be missed until social demands highlight the person’s differences (APA, 2022).

First identified in 1943 by psychiatrist Leo Kanner, autism was listed diagnostically by the APA in 1980 and has undergone various diagnostic changes over the years, until 2013 when Asperger’s disorder and other related disorders were combined under the domain of autism spectrum disorder (Kring et al., 2016). Accompanying this shift is the development of views that move beyond the deficit-based medical model of the DSM-5 descriptions to position autism as a neurological variability and acknowledge the part that societal norms and assumptions play in stigmatising individuals whose actions originate from different life worlds (Kapp, 2020; Milton et al., 2023). Rather than viewing autistic traits as inherently disordered, these affirming viewpoints emphasise the context and dynamics of two-way communication and recognise that actions originate from different embodied experiences (Milton et al., 2022). This broader, non-deficit model is especially important when considering the contextual nature of intimate relationship communications and interactions.

With rising numbers of late-diagnosed adults (Bullen & Qadar, 2021; Kring et al., 2016; Meng-Chuan & Baron-Cohen, 2015) and the current limited focus on autistic adult services (Nathenson & Zablotsky, 2017), the availability and evaluation of adult interventions has been recommended (Nathenson & Zablotsky, 2017), along with development of non-deficit approaches to support and interventions (Milton et al., 2022). This paper focuses on interventions for neurodivergent adults in romantic relationships where one or both are autistic, identified either through formal diagnosis or self-identification. In this article, these couples are referred to as neurodiverse (ND).

Background

A main contributing factor to adult quality of life is that of successful interpersonal relationships, and autistic adults are no different in this respect (Mason et al., 2018). Increased feelings of wellbeing and self-esteem are a by-product of healthy and supportive intimate relationships (Voss et al., 1999, as cited in Roberson et al., 2018), which can also temper effects of anxiety and depression (Bastida-González et al., 2017; Hasan et al., 2021). Conversely, couple discord can cause psychological distress, as well as impair social and employment experiences, separate from any underlying disorders that may be present (Whisman & Uebelacker, 2006).

Autistic adults of all levels of functioning are likely to have been in a romantic relationship (Strunz et al., 2017). They typically show positive relationship attributes such as genuineness, loyalty, honesty, commitment (Yew et al., 2021), and altruism (Rosqvist & Jackson-Perry, 2021). However, adults on the autism spectrum are likely to have experienced more limited opportunities for social development as adolescents than their neurotypical peers (Byers et al., 2013). Social difficulties often play out within relationships between autistic and non-autistic adults, who each have differing communication skills and social expectations, affect regulation, social reciprocity, and adaptive behaviour skills (Kring et al., 2016; Magiati et al., 2014). These difficulties occur regardless of the overall cognition and language capabilities of autistic individuals (Saulnier & Klaiman, 2022). The unique challenges that result include the “double-empathy problem”, a term developed by Damien Milton (2012) that describes the difficulty autistic and non-autistic adults have in interpreting each other’s inner states and motivations (Milton et al., 2022). This can lead to non-autistic partners feeling emotionally unsupported by their autistic partner (Goldstein Hode, 2014) and autistic partners struggling in part with the unspoken expectations of their non-autistic partners (Winn et al., 2016).

Relationship Counselling

Relationship counselling plays an important role in many relationships. Such counselling can strengthen relationship functioning and provide beneficial long-term outcomes (Fischer et al., 2016; Roesler, 2020), as well as enhance individual wellbeing (Winter et al., 2021). Numerous relationship-counselling models have proven effective in reducing distress and improving long-term outcomes for partnerships. For example, in their systematic review of emotionally focused couple therapy (EFT), Beasley and Ager (2019) found evidence of strong levels of effectiveness in relation to reduced emotional distress and sustained positive change, including for specific populations such as couples that include veterans with post-traumatic stress disorder, and couples with teenage children.

Access to effective couple therapy that is adjusted to suit ND relationships is just as important as it is for other non-normative groups. Owing to the unique characteristics and challenges of ND relationships, when they experience discord, therapeutic approaches should recognise the part that differences in sensory, cognitive, emotional, and behavioural traits play in the relationship dynamics to help the couples move forward towards positive, mutually supportive relationships (Goldstein Hode, 2014). EFT has attachment theory at its basis and integrates an experiential perspective that focuses on emotional responses, using them to facilitate therapeutic change (Johnson et al., 2022). Yet, because of the inherent difficulties experienced by autistic adults in identifying and expressing emotions, the question arises whether EFT is a suitable therapy to apply to ND couples. Likewise with other evidence-based therapeutic models such as acceptance and commitment therapy for couples (Lawrence et al., 2022), behavioural couples therapy (Halford & Pepping, 2019), Gottman couple therapy (Davoodvandi et al., 2018), mindfulness-based couple interventions (Winter et al., 2021), or with systemic practices such as Post-Milan, solution-focused brief therapy, or narrative therapy, the characteristics and focuses of these interventions might not align with both an autistic outlook and non-autistic way of being within the therapeutic approach in a way that produces positive change.

To explore whether this issue has been addressed in the literature, an initial search of academic databases was conducted for systematic or scoping reviews on the topic of relationship counselling specific to couples that include autistic adults. Just one systematic review, conducted in 2012 by Bostock-Ling et al., was found. This review focused on the relationship satisfaction and intervention models for relationships involving an Asperger’s syndrome partner and a neurotypical woman and identified 10 relevant studies. None were intervention studies, and so the review found no empirical evidence on which to base intervention recommendations for these types of relationships. The identification of just one review, which in itself was focused on a subsection of the population in question, and moreover that none had been conducted since 2012, highlighted a considerable gap in the literature. Therefore, this scoping review set out to examine what is currently known about relationship counselling for romantic relationships in which at least one partner is autistic.

Method

Scoping reviews provide a systematic way to synthesise evidence on a particular topic and aim to identify key characteristics of the focus concept and the breadth of literature available (Munn et al., 2022). The scoping study methodology advanced by Levac et al. (2010) from Arksey and O’Malley’s methodological framework (2005) guided the review presented in this paper. Since this was not primary research, no ethics approval was deemed necessary.

Stage 1: Identifying the Question

Question formulation considered population, concept, and context, as recommended by the Joanna Briggs Institute (JBI; Aromataris & Munn, 2020). The population focus was autistic adults and their romantic partners, who were either autistic or non-autistic. The autistic population included adults diagnosed with Asperger’s syndrome, because this diagnostic term was subsumed under the wider diagnostic domain in 2013, and autistic adults who self-identified. This level of inclusion recognised that the literature was likely to have used a range of identification methods and considered the difficulties and mixed motivations related to gaining a diagnosis in adulthood (see Bargiela et al., 2016; Bullen & Qadar, 2021; Huang et al., 2020). The concept focused on relationship therapy recommendations specific to the needs and profiles of autistic adult intimate relationships, while the context comprised studies written in English from any country and published since 2012, when the last related review had been conducted.

Accordingly, the research question and sub-questions developed were as follows: What is currently known about relationship counselling for romantic relationships in which at least one partner is on the autism spectrum?

1. What adaptations that take a non-deficit approach are recommended for relationship therapy?

2. What are the rationales given for making these therapeutic adaptations?

3. Which therapies show evidence of effectiveness for the target population?

4. What are the limitations of the research?

5. What are the literature gaps for this population and concept?

Stages 2 and 3: Search and Selection Strategies

After refinement of the research question and consultation with a research librarian, academic databases were selected and searched on 2 September 2022. These databases were ProQuest One Academic, Sage Journals, Scopus, and EBSCOhost Megafile Ultimate, which included Academic Search Ultimate, E-Journals, Humanities Source Ultimate, APA PsycArticles, Psychology and Behavioral Sciences Collection, APA PsycInfo, and Sociology Source Ultimate.

The search strings used related to the defined population and concept, specifying the terms (“romantic relationships” OR “intimate relationships” OR couples) AND (neurodivers* OR autism) AND (communication OR counseling). Search strings were applied to the document fields of title and abstract of studies available in English with publishing dates after 2012. Two separate searches of each database were conducted using the same search strings listed above, firstly, to extract peer-reviewed journal articles and, secondly, to extract dissertations on the topic. After the inclusion and exclusion criteria had been applied and articles identified for the scoping review, the references of these articles were searched and any further relevant articles found were screened. All identified articles were saved to the Endnote X9 software program, then duplicate articles were removed from the list.

Following this, the inclusion and exclusion criteria were applied systematically. Initially, a pilot screening of 10% of the articles was conducted. These results were compared with the results of a colleague who screened the same selection of articles; any discrepancies were resolved through discussion.

At this initial stage, the author recognised that modifications to the criteria were required, for two reasons. Firstly, several articles identified were not primary research articles but had not been captured by the exclusion criteria. Secondly, several articles met the exclusion criteria of not focusing on autistic adults, due to their population focus of neurotypical partners of autistic adults, but otherwise met all other inclusion criteria and seemed worthy of inclusion when considering the main research question. After consultation with colleagues and the scoping review supervisor, the inclusion criteria were modified to exclude studies that were not primary research and to include studies that focused on either autistic adults or their neurotypical partners. The final inclusion and exclusion criteria applied are detailed in Table 1.

The pilot screening of 10% of the articles by the author and a colleague was then repeated with the updated criteria, and the results were compared. Subsequently, the remaining article titles and abstracts were screened. These screenings were approached conservatively: if doubt arose regarding the applicability of the criteria, the article was included for full text screening.

Following this, the same inclusion and exclusion criteria were applied to assess the full text of 10% of the screened articles for inclusion. The results were compared with a colleague’s screening results of the same articles, and any discrepancies were resolved before all remaining articles were assessed for eligibility for inclusion. The articles that remained after this process were the articles reviewed in this scoping review.

Stage 4: Extracting, Mapping, and Charting the Data

Following the article screening and selection process, data were extracted by the author using a modified JBI template (Aromataris & Munn, 2020) as the data extraction framework. This framework was maintained for each article. The article elements extracted were the bibliography details of the author and year of publishing, the country of origin, the type of study design, the population focus and the participants involved, the research question, the study results, the study recommendations, and the strengths and limitations. Other aspects relating to the review sub-questions—namely, whether a non-deficit approach had been taken, the rationales given for any therapeutic adaptations, and the evidence of effectiveness (if any) of the recommendations—were also noted in the framework.

The results of the screening methods outlined above are summarised in the PRISMA flow diagram put forward by Moher et al. (2009), illustrated in Figure 1. Three-hundred and thirty-six articles were initially identified through database searches, and eight additional articles through a reference search. Duplicate removal reduced this number to 111 articles. These articles were then screened. Reasons for exclusion of articles at each stage are noted in Figure 1. These reasons related to the exclusion criteria, which across the whole screening process excluded four articles that did not present primary research, 57 articles that did not involve either autistic adults or their romantic partners, 22 articles that did not involve adults in current relationships, and 19 articles that were not related to relationship counselling. After applying the inclusion and exclusion criteria to titles and abstracts, 23 articles remained. Following full text assessment, nine articles were deemed relevant to the scoping review and suitable for inclusion.

Figure 1.PRISMA Diagram of Article Screening and Selection

Note. From “Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement”, by D. Moher, A. Liberati, J. Tetzlaff, D. G. Altman, and The PRISMA Group, 2009, PLoS Medicine, 6(7), Article e1000097 (doi:10.1371/journal.pmed1000097). CC BY-NC.

The data extraction process detailed above was then applied to the nine articles. Articles were read several times to aid familiarity, and details were added to the data extraction framework. Themes that emerged from the data during this process were noted and used in the synthesis phase to group the findings. The characteristics of each included article are summarised in Table 2, namely, the author and country of the study, the study design, the participant population, the aims or research question of the study, details of the findings, and finally the therapeutic recommendations made for relationship counselling for partnerships involving autistic partners. A methodological quality assessment of these articles is not included since this was beyond the scope of this review.

Stage 5: Synthesis of Results

Many of the studies had been very recently published. Publishing dates of the nine articles ranged from 2015 to 2022, and four of the studies had been published in either 2021 or 2022. More than half of the studies were from the USA (Bolling, 2015; L. F. Lewis, 2017; Marcotte, 2018; Mitran, 2022; Parker & Mosley, 2021), two studies were from Australia (Smith et al., 2021; Wilson et al., 2017), and one each from Israel (Engelhard & Vulcan, 2021) and England (R. Lewis, 2016).

The aims of each study varied. Two aimed to investigate specific relationship-counselling approaches (Engelhard & Vulcan, 2021; Parker & Mosley, 2021). In contrast, the remaining seven studies investigated the experience of being in an ND relationship: two explored the perspective of the neurotypical partner only (L. F. Lewis, 2017; Marcotte, 2018), one examined the neurodivergent partner’s experience (Mitran, 2022), and four examined the experiences of both partners (Bolling, 2015; R. Lewis, 2016; Smith et al., 2021; Wilson et al., 2017).

Of the nine included articles, only one had employed a quantitative study design. This study (Bolling, 2015) surveyed ND couples using the Marital Satisfaction Inventory, Revised (MSI-R; Snyder, 2004, as cited in Bolling, 2015) to compare levels of satisfaction and distress in ND relationships compared with the norm. Bolling (2015) found statistically significant elevated levels of relationship distress in ND couples—in particular, elevated distress in the neurotypical partners—for each of the survey indicators. Bolling (2015) made relationship-counselling recommendations based on these findings.

The eight other studies reviewed were qualitative studies employing a variety of research designs. Engelhard and Vulcan (2021) conducted a literature review on dance movement therapy (DMT) for couples and for autistic adults, while Parker and Mosley (2021) conducted an evidence-based case study to evaluate the effectiveness of a 12-session course of solution-focused brief therapy (SFBT) for one ND couple. In their examination of the experiences and interactions within ND relationships, L. F. Lewis (2017) and Marcotte (2018) each conducted a thematic analysis on the reported experiences of partners of autistic adults—the first from written responses to a prompt, and the second from three published autobiographical accounts. R. Lewis (2016) and Wilson et al. (2017) took grounded theory approaches and interviewed members of ND couples before forming theoretical frameworks of interaction. Meanwhile, Smith et al. (2021) used a phenomenological approach when interviewing ND couples and identified four major themes to describe the stages of an ND relationship. Finally, Mitran (2022) undertook a discourse analysis of interviews of three autistic adults regarding their communication experiences and incorporation of technology before applying this to ND relationship-counselling practice.

Putting aside the single literature review, the demographic profiles of the ND relationships represented in the direct research studies had many similarities. Several studies mentioned striving for diversity when sourcing participants (Bolling, 2015; R. Lewis, 2016; Wilson et al., 2017). In seven of the studies (Bolling, 2015; L. F. Lewis, 2017; R. Lewis, 2016; Marcotte, 2018; Parker & Mosley, 2021; Smith et al., 2021; Wilson et al., 2017), a combined total of 199 participants represented mostly autistic male and non-autistic female partnerships. Of these partnerships, only three were same-sex relationships and four were relationships in which both partners were autistic. In relation to the participants, only 37 were autistic women, while 65 had children. When mentioned, ethnicity was overwhelmingly White; of the 199 participants, just one Chinese and one mixed-race Caribbean participant were noted.

Considering the scoping review research question exploring what is currently known about relationship counselling for romantic ND relationships, the studies agreed about the lack of population-specific relationship counselling and the requirement to adjust general counselling approaches in order to meet these couples’ needs, which included addressing the reasons for their higher levels of distress and catering for unique ND relationship challenges. Further results are grouped under the headings below.

Availability of Counselling Support

Smith et al. (2021) explored through interviews with ND relationship partners their perceptions of relationship support services. They collected reports of inadequate assistance and a lack of understanding of autism from health professionals (Smith et al., 2021). Many of the study participants emphasised the lack of appropriate services for ND couples and difficulty in finding resources (Smith et al., 2021). L. F. Lewis (2017) reported findings of partners of autistic adults feeling isolated regarding their experiences and unable to find appropriate professional assistance. These partners had poorer mental health outcomes, were tolerating abusive and unhealthy behaviours, and demonstrating their own emotionally abusive behaviours towards their partners (L. F. Lewis, 2017).

Existing Counselling Models

Striving for a non-deficit and positively focused approach to relationship counselling for ND couples, Parker and Mosley (2021) implemented a case study to examine SFBT for an ND couple. After 12 sessions, positive outcomes were seen in measures of communication discomfort and emotional awareness discomfort for both partners; however, relationship satisfaction measures did not show improvement (Parker & Mosley, 2021). The authors suggested that with modifications, comprising a longer intervention duration, therapist familiarity with autism, specific goals of autistic acceptance and social support, and incorporation of integrative behavioural couple therapy (IBCT; see Barraca et al., 2021), greater relationship satisfaction might be achieved (Parker & Mosley, 2021).

In their literature review, Engelhard and Vulcan (2021) were unable to locate any DMT studies focusing on ND couples, although they did find DMT studies relating to individual autistic adults. These DMT interventions for individuals incorporated many of the same aspects as DMT for couples, such as synchronisation, mirroring, imitation, and verbal processing, with the aim of enhancing the ability to recognise another’s emotional expression and feelings (Engelhard & Vulcan, 2021).

R. Lewis (2016) and Marcotte (2018) each discussed attachment theory in relation to couple therapy. R. Lewis (2016) emphasised a need to balance elements of attachment with a structural family therapy approach (Minuchin et al., as cited in R. Lewis, 2016). Marcotte (2018) was more explicit, stating that while EFT with its foundational attachment theory would be valuable on an individual basis for the non-autistic partners, it was not recommended as a relationship-counselling approach for ND couples. Instead, Marcotte (2018) suggested that therapies providing tools and scripts for receiving and expressing emotions, such as relationship enhancement therapy (Scuka, 2005, as cited in Marcotte, 2018) would be more beneficial.

Marcotte (2018) referred to and recommended a previously published couple therapy model specifically written for ND relationship counselling. This was Thompson’s seven-stage model, which (a) recognises the importance of diagnosis and understanding of autism, (b) seeks individual counselling for each partner to explore their relationship needs and desires, (c) engages both partners in couple therapy, (d) acknowledges within therapy the different perspectives and awareness of how each partner speaks a different language, (e) includes visual aids to help the autistic partner gain deeper understandings of therapy discussions, (f) helps the couple formulate strategies for overcoming difficulties, and (g) encourages each partner to seek ongoing support and personal space (2008, as cited in Marcotte, 2018).

Wilson et al. (2017) suggested that an implementation of dynamic systems theory (DST; Megremi, 2014, as cited in Wilson et al., 2017) would prove valuable. According to the authors, employing DST could highlight the importance of task constraints in social contexts, which would lead to effective intervention strategies for ND partnerships.

Therapist Understanding of Autism

Many of the studies emphasised the importance of an up-to-date therapist understanding of the variable presentation of autism. For example, Smith et al. (2021) found that both understanding of autism and the provision of appropriate help from relationship support services were lacking, while Parker and Mosley (2021) proposed that adjustments to their case study of SFBT, to ensure greater therapist familiarity with autism, could improve relationship satisfaction results. Meanwhile, Mitran (2022) noted five criteria for therapists to practise and demonstrate themselves first in order to ensure successful therapeutic interventions when working with neurodivergent people. These were “(a) cognitive empathy, (b) perspective taking, (c) personal awareness, (d) paradigm shifting, and (e) intersubjectivity” (Mitran, 2022, p. 439).

Marcotte (2018) cited Lorant (2011) when advising that therapists acquire a clinical understanding and working knowledge of autism when considering working with ND couples. Furthermore, L. F. Lewis (2017) noted the power of therapist awareness and validation of client experience in the relationship-counselling process, especially in relation to her findings of non-autistic partner isolation and distress. Accompanying this observation, the author recommended that therapists are vigilant about partner violence from either partner and seek education on boundaries and expectations (L. F. Lewis, 2017). Wilson et al. (2017) underscored the importance of ensuring in-depth therapist understanding of ND communication patterns by developing a model of the complexity in the interconnection between needs, roles, and expectations seen in the prompt-dependency cycle that can develop in ND relationships. Bolling (2015) also advocated for screening measures for broader autism phenotypes during client intake to inform the treatment approaches better.

The first of this review’s sub-questions asked: What adaptations that take a non-deficit approach are recommended for relationship therapy? Multiple adaptations were recommended in the studies and are grouped under the headings below.

Dance Movement Therapy

Engelhard and Vulcan (2021) recommended adapting DMT as a suitable intervention for ND couples. The authors proposed that combining the existing protocols of DMT for couples with DMT for autistic adults would help ND couples develop mutual empathy and interpersonal communication, so that healthy intimate relations can be fostered and maintained.

Cultural Lens Approach

Many studies, including Marcotte (2018) and Smith et al. (2021), advocated approaching ND relationships with a cultural lens. Smith et al. (2021) expanded on the theme of intercultural relationships, stating that ND relationships appeared to fit into a “coexisting” intercultural relationship structure (Tili & Barker, 2015, as cited in Smith et al., 2021), whereby individuals in couples retain much of their own culture, but view their differences to be an attractive asset. R. Lewis (2016) suggested normalising mismatched understandings as a process of relationships in general, while Mitran (2022) suggested that counsellors interpret ND relationships as those in which the partners speak two different languages, with the counsellor acting as an interpreter to bridge the gaps in perspectives and needs between partners. Bolling (2015) recommended viewing autistic traits as valid alternatives, while L. F. Lewis (2017) and R. Lewis (2016) advocated fostering mutual understanding and validation of each partner’s experiences within counselling. The issue of perspective taking was emphasised by Mitran (2022), who proposed the use of adaptive technologies such as tailored virtual reality to assist in this area. Strengthening empathy was a valuable therapeutic goal in DMT for ND couples described by Engelhard and Vulcan (2021). Meanwhile, Parker and Mosley (2021) suggested using therapist-set goals centring on acceptance of autism.

Social Support

Numerous studies emphasised the need for social support for the neurotypical partner (Bolling, 2015; Marcotte, 2018; Parker & Mosley, 2021). For example, Bolling (2015) highlighted an approach to support non-autistic women in ND relationships called “SALVE” (Families of Adults with Aspergers’ Syndrome, 2013, as cited in Bolling, 2015), which emphasises the self-explanatory elements of support, assistance, listening, validating, and education for these women to increase positive outcomes and feelings of wellbeing.

Communication and Daily Living Strategies

The creation of practical systems to enhance communication and a more functional daily life was advocated in several studies. Bolling (2015) suggested specific coaching to learn how to respond to partner distress; the use of timers, notes, and reminders to help the autistic partner remember regular meaningful rituals for their spouse, such as calling throughout the day; and the use of the social thinking intervention program (Winner, 2014, as cited in Bolling, 2015) to develop core theory of mind skills. Bolling (2015) also suggested creating systems to divide the burden of parenting tasks equally.

Wilson et al. (2017) advocated interventions to encourage non-autistic partners to explicitly state the social rules for reciprocal interactions, and their needs relating to emotional connection, in order to avoid a prompt-dependency cycle of communication becoming embedded. Related to emotional connection, L. F. Lewis (2017) recognised the potential need for specific counselling concerning sexual engagement to address struggles with physical contact or sensory hypersensitivity in the autistic partner, and to help the non-autistic partner develop clear signals for the initiation of sexual intimacy. L. F. Lewis (2017) also suggested strategies taken from The Asperger’s Couple’s Workbook (Aston, 2009, as cited in L. F. Lewis, 2017), which included the use of code words to signal overwhelming feelings or the need for alone time. Finally, Parker and Mosley (2021) suggested that a model such as IBCT, which deals with relational conflict (Barraca et al., 2021), may increase relationship satisfaction rates, especially for the non-autistic partner.

Discussion

In terms of the prime scoping review research question regarding what is currently known about relationship counselling for ND couples, the answer is that not much is known. The scoping review revealed nine studies, of which only two related to a relationship therapy model, and only one of which trialled a therapeutic model (Parker & Mosley, 2021). This dearth of empirical research into counselling approaches for ND relationships represents a deficit in the autism field of research.

From the studies, many similar themes emerged. Firstly, the consensus view of almost all the studies concerns the lack of availability of suitable relationship therapy for ND couples (Bolling, 2015; L. F. Lewis, 2017; R. Lewis, 2016; Marcotte, 2018; Mitran, 2022; Parker & Mosley, 2021; Smith et al., 2021; Wilson et al., 2017).

Secondly, lack of therapist awareness of autism was a critical factor inhibiting successful outcomes, and therefore tailored psychological support for ND couples was needed. This finding from many of the studies concords with Gilmore et al. (2022), who found that a lack of autism-trained providers affected the quality of care of autistic adults. L. F. Lewis (2017), R. Lewis (2016), Mitran (2022), Parker and Mosley (2021), and Smith et al. (2021) all advocated for therapist awareness and an understanding of autistic variability, while Marcotte (2018) suggested psychoeducation and therapies to facilitate the acceptance of a diagnosis, which necessitate therapist familiarity with autism.

Advocacy of therapist familiarity aligns with the central relationship-counselling principle of being consistently attuned to each client within the therapeutic space (Johnson et al., 2022), which breaks down when the therapist is unfamiliar with an autistic client’s experience of the world. Therapists’ familiarity with autism and willingness to adapt approaches were also advocated by Gilmore et al. (2022), who stated that taking a rigid approach to care for autistic adults—including inflexibility regarding the client’s potential need for more time to establish rapport and address challenges associated with expressive and receptive language—results in poor outcomes.

Non-Deficit Approaches to Recommended Adaptations

The first sub-question of this review asked what adaptations that took a non-deficit approach were recommended for relationship therapy. Four of the nine studies reviewed had been published in 2021 or 2022, and this most recent research was correlated with greater inclusion of the autistic adult perspective or experience within the study designs (see Engelhard & Vulcan, 2021; Mitran, 2022; Parker & Mosley, 2021; Smith et al., 2021). This autistic perspective inclusion aligns with the general view of the neurodiversity movement that seeks to privilege the lived experience of autism in public arenas and in research involving autistic people (Kapp, 2020).

Apart from this inclusion of an autistic perspective, all of the studies demonstrated evidence of a non-deficit approach in other ways. The strongest indication was the advocacy present in all articles for viewing each partner as both having challenges and being able to address challenges and adapt, rather than relying on just one partner to adapt, or viewing one partner as being either incapable of adapting to change or not needing to adapt (Bolling, 2015; Engelhard & Vulcan, 2021; L. F. Lewis, 2017; R. Lewis, 2016; Marcotte, 2018; Mitran, 2022; Parker & Mosley, 2021; Smith et al., 2021; Wilson et al., 2017). This advocacy was moderated with a recognition of the differences in levels and types of support to enable these adaptations. The intercultural relationship perspective of ND partnerships suggested in many of the studies (Marcotte, 2018; Mitran, 2022; Smith et al., 2021) is further evidence of an autistic brain style being viewed as a difference to be accepted rather than as a deficit to be changed. This aligns with the wider view from the general autistic community of understanding autism in terms of human rights and as an acceptable identity in itself (Kapp, 2020), rather than as a deficit to fix.

Various other recommendations arose from a non-deficit approach to ND relationships. Two such were provision of social support for the non-autistic partner (Bolling, 2015; Marcotte, 2018; Parker & Mosley, 2021) and an emphasis on communication and daily living management strategies (Bolling, 2015; L. F. Lewis, 2017; Parker & Mosley, 2021; Wilson et al., 2017). By addressing specific needs and challenges within the relationship dynamic, these recommendations avoid viewing either partner as deficient.

Engelhard and Vulcan (2021) took a different approach when making non-deficit ND relationship-counselling recommendations in their study. After their findings of successful DMT intervention outcomes for couples and also for autistic adult individuals, they put forward a proposal for further research into an ND relationship DMT intervention. Incorporated into this proposal were the elements of mirroring, synchronisation, and mutual coordination, supported by verbal discourse, with the aim of strengthening the development of emotional cognition and empathy within the relationship dynamic.

Rationales for Adaptations

The second sub-question of this study asked what rationales were given for any proposed therapeutic adaptations. When considering this question, the research articles can be divided into two groups according to the type of research findings from which the ND relationships recommendations are drawn. The first group, comprising Engelhard and Vulcan (2021) and Parker and Mosley (2021), examined a particular therapeutic approach, then made recommendations regarding these interventions, noting adjustments deemed necessary or worthy of further research. The other group, comprising Bolling (2015), L. F. Lewis (2017), R. Lewis (2016), Marcotte (2018), Mitran (2022), Smith et al. (2021), and Wilson et al. (2017), examined the lived experiences of members of ND relationships before drawing conclusions and offering practical suggestions about the types of specific strategies to incorporate into ND relationship therapy.

Much of the rationale behind recommendations related to the various interview and survey findings that revealed the distress of partners. Communication difficulties within the relationship and the lack of felt emotional support for non-autistic partners were evidential in the marital satisfaction survey data from the quantitative study by Bolling (2015). L. F. Lewis (2017) found from interviews of non-autistic partners that common areas of challenge were communication and a lack of sexual intimacy expectations, as well as evidence of unhealthy and abusive behaviours from both partners in the relationship. Mitran (2022) found in her study of three autistic adults that communication expectations, including the reading of non-verbal signals, was a challenging and stressful component of interactions. Furthermore, Smith et al. (2021) in their interview results of both partners from ND relationships found communication difficulties to be a main challenge, along with differences in expressing and interpreting emotions. Wilson et al. (2017) in a focused study with nine ND couples found the development of a prompt-dependency cycle occurring in interpersonal interactions, which the authors viewed as a specific communication difficulty in such partnerships.

Evidence of Effectiveness of Therapies for Neurodiverse Relationships

The third sub-question asked what therapies showed evidence of effectiveness for the target population. When formulating this question, it was hoped that research regarding specific therapeutic models would form the majority of the literature sourced for the review, but this was not the case. In the two studies in the review relating to specific models, some evidence of effectiveness was found. The DMT models were found by Engelhard and Vulcan (2021) to be effective for autistic individuals, and the authors used this finding to propose expanding the protocol for ND couples. Some evidence of effectiveness for certain measures of distress in the single SFBT case study was also observed (Parker & Mosley, 2021).

While many quite specific recommendations were made in the literature, almost none of these were subjected to empirical research protocols. Several recommendations referred to previously published couple therapy models specifically written for ND relationship counselling, such as Thompson’s (2008, cited by Marcotte, 2018) seven-stage model and the Asperger’s Couple’s Workbook (Aston, 2009, as cited in L. F. Lewis, 2017), which has since been revised and expanded to be The Autism Couple’s Workbook (Aston, 2021). These models, however, are from the grey literature on the topic, rather than from peer-reviewed research.

Limitations and Literature Gaps in the Research

The fourth sub-question asked what the limitations of the research were. Seven studies referenced the lack of true representation of the study population regarding being able to generalise the results to other ND couples (Bolling, 2015; L. F. Lewis, 2017; R. Lewis, 2016; Marcotte, 2018; Parker & Mosley, 2021; Smith et al., 2021; Wilson et al., 2017). Moreover, Parker and Mosley (2021) identified the possible subjective application of the SFBT approach by the individual therapist as another limitation of their study.

The final sub-question asked what the literature gaps were in relation to this population and concept. As noted earlier in the discussion, there was an evident lack of empirical research on established relationship-counselling models for the ND population, and only one study yielded research on a relationship-counselling model (Parker & Mosley, 2021). Most of the studies noted this research gap (Bolling, 2015; Engelhard & Vulcan, 2021; L. F. Lewis, 2017; R. Lewis, 2016; Marcotte, 2018; Mitran, 2022; Parker & Mosley, 2021; Smith et al., 2021) and several advocated for more research to examine particular focuses, such as gender influences within autism (R. Lewis, 2016), non-White ND couples (Marcotte, 2018), same-sex ND couples, and couples in which both partners are on the autism spectrum (L. F. Lewis, 2017).

Limitations of this Review

This scoping review has several strengths and limitations. Strengths include the collaboration between the author and a research supervisor, colleagues, and research librarian when formulating the specific research question, search protocol, and inclusion and exclusion criteria. The primary (title and abstract) and secondary (full text) screenings were each conducted on 10% of the articles, then compared with a colleague’s screening results prior to the author continuing to screen the article list.

One limitation is that articles that might have been relevant to the scoping review might have been missed in the search process. A research librarian was consulted in the formulations of search strings and relevant databases. After several test searches, it was considered necessary to combine the search term “relationship” with the words “intimate” and “romantic” to avoid an unwieldy number of articles unrelated to the concept being selected. This might have resulted in relevant articles being missed in the search. To combat this somewhat, a search through the reference list of final selected articles was conducted, which yielded nine extra results for screening, as seen in the PRISMA diagram, none of which passed the screening stage. Nevertheless, it is likely that other relevant articles were not found.

Related to this, is the limitation of the inclusion requirement for English written articles. Although translated articles from non-English-speaking countries were able to be included in the screening process, the countries of publication of the studies were skewed towards English-speaking countries. It is likely that relevant studies were excluded owing to this review requirement. The exclusion of grey literature, deemed to be beyond the scope of this review, would also have narrowed the findings.

Conclusion

This scoping review aimed to find what is currently known about relationship counselling for romantic relationships in which at least one partner is autistic. It examined the recommended therapeutic adaptations that took a non-deficit approach, the rationales given for the adaptations, and any evidence of their effectiveness in ND relationships.

This review has several key implications for relationship therapists. An important finding is the recommendation of numerous studies to take an intercultural perspective of the differences between non-autistic and autistic partners, which avoids viewing autism as a deficit when dealing with relationship difficulties. This frame of reference can be a useful overarching structure for therapists to foster greater understanding of relationship dynamics.

Other important therapeutic recommendations advocate for therapist familiarity of autistic adults and how ND relationships differ in terms of communication, emotional engagement, and reciprocity. Routine screening of clients for autistic traits on intake can better inform treatment approaches. The potential for high levels of distress in non-autistic partners needs to be recognised and validated, and the use of wider social supports for these partners encouraged. The potential for boundary violations and the need to check for domestic violence is present for these relationships, as it is for others.

Emotionally focused therapy was explicitly not recommended for ND couples in one study, while another study suggested that application of attachment theory should be balanced with more structured activities. EFT was, however, recognised as potentially helpful for individual therapy with the non-autistic partners. The practical application of strategies such as technology assistants for reminders, virtual reality for expanding perspectives, and visual representation of concepts during counselling was also encouraged. DMT for couples and other relationship therapy models such as SFBT and IBCT were noted as worthy of further research and holding potential application for ND couples. Finally, the proportion of recently published studies that constituted this review is a possible indication that further research may occur in the near future. Hence, this review can provide valuable direction for future research.