236. When Autism and OCD Overlap with Nikole Krueger, LMSW

Carrie: Welcome back, everyone. We are here with Nicole Krueger again. You may remember her from our episode that we did on the overlap of ADHD and OCD, and today she’s back to talk with us about the intersection of autism and OCD, so I’m very excited about this conversation as well

Nikole: Welcome, OCD warriors, to the Christian Faith

Carrie: and OCD podcast, where we are all about reducing shame and stigma of struggling with OCD as a Christian, sharing hopeful stories, and replacing uncertainty with faith as you develop practical tools for greater peace.

I’m Carrie Bach, Christ follower, wife, mom, and licensed professional counselor in Tennessee. I pray you are blessed by today’s episode And Nicole is a LMSW who practices online and in Grand Rapids, Michigan. So if you’re in Michigan, you can find her at Nicole Kruger Counseling. We’ll put her website in the show notes.

Nicole, welcome back. Glad to have you here.

Nikole: Yeah, thanks for having me again.

Carrie: How would you define autism for someone?

Nikole: Autism is really neurological difference or a difference in the person’s nervous system. Estimates are that it is, that over 2% of the world’s population is autistic, so that’s a lot bigger number than we previously really thought of in terms of having autism.

It’s very much a genetic disorder, a genetic difference, I will say. It’s not a psychological disorder, so similar to ADHD, it’s something that you’re born with that persists throughout life, and that really impacts how you experience and process and respond to the world and to the different inputs to your nervous system.

It can impact how people experience different external and internal sensations, so like think hunger, thirst, pain, noise, texture, light. It can impact movement patterns. A lot of people are familiar with the concept of stimming, um, or self-stimulation. It can impact communication styles. Autistic people generally-

Carrie: Yeah, things like flapping hands or, like, what kind of stimming behaviors might you see with someone?

Like, what might they look like?

Nikole: Yeah. Stimming can take the form of flapping. A lot of, like, lower support need autistic people won’t necessarily do that publicly, maybe in private, but a lot of people are aware that’s not really a socially preferred type of behavior, and so they’ll mask that. They might do more acceptable types of behaviors that might even just be, like, fiddling back and forth with an object.

It might be kind of like mild rocking back and forth. A lot of autistic people that I know love, like, swinging.

Carrie: Okay.

Nikole: Even backyard swings. Again, that’s not something that you’re necessarily gonna see when you’re out in public, but in private, finding those ways to self-soothe. It can even be sometimes, like, skin picking or scratching or rubbing fingers together.

Carrie: Okay.

Nikole: So different things like that.

Carrie: Yeah. How is this, the different views of autism in terms of it as a medical disorder versus this idea of neurodivergence?

Nikole: Historically, they’ve kind of looked at autism more from a medical model of a disability or a defect within a person, and so looking at it in terms of there’s a normal way of being, and then anything that’s significantly outside of that is seen as a flaw that requires correction, right?

Now, we’ve moved more towards a neurodiversity paradigm, which is much more humanizing for people who are autistic, and looking at seeing autism more as a natural form of human variation. Not a genetic mistake, but just that brains come in a lot of different varieties, and that the disability Really comes from the mismatch between the person and their environment, and that when that fit is poor, that creates these difficulties in compensation that cause kind of the outward impacts of autism that people struggle with, and that can cause a lot of misunderstanding or overwhelm in social situations or causing anxiety and such.

Carrie: I think this is an important distinction when we talk about intelligence, right? Because there are people who deal with autism who are quite intelligent, whereas if you look at it as a disability, like, that doesn’t seem to line up with what we know about other intellectual disabilities, for example.

Nikole: Yeah.

And with autism, we do see higher than in the neurotypical population percentage of people who have neurodiversity as also having, like, learning disabilities or intellectual impairment, but that’s not the whole spectrum. And so many years ago used to be where we had the autism diagnosis, and then there was Asperger’s, which was considered kind of that, like, lower support needs end of the autism spectrum, and now it’s all considered autism spectrum disorder, which there’s even debate over that.

A lot of autistic people don’t like that phrasing either.

Carrie: Right.

Nikole: But looking at it as a spectrum, and one end of the spectrum we have more of the intellectual impairment and disability overlap, but those are two separate things.

Carrie: Sure.

Nikole: Autism does not encapsulate the intellectual impairment aspect within its diagnosis.

That’s a separate diagnosis that does often overlap on that end of the spectrum. But then we also have the other end of the spectrum. Of course, it’s, it’s continuous, but on the other kind of end of it, we can see very high intelligence in fact, and even sometimes people who are considered, like, savant level, highly intelligent, and have incredible abilities in certain areas.

But that is a big way that I think many people have been missed in the autism diagnostic process because we were for so long only looking at people that had outwardly visible Characteristics of like arm flapping and intellectual disability and things like that, where it was evident from a very young age or under that there were significant differences in their social functioning, versus all the kids that have grown up and have found ways to get by and to lead relatively successful lives or struggle, but have made it to adulthood without being detected through masking and through just lack of information and awareness out there of what autism actually is.

And that can lead to also a lot of just shame and discouragement from not understanding your brain and how it functions, and taking a perspective that this is something wrong with you rather than just that you have a different type of nervous system that needs to be accommodated differently.

Carrie: I think one of the challenges is determining maybe what’s the difference between someone who, or a child or an adult who’s dealing with some type of social anxiety, like they’re really struggling to make social connections because they’re anxious, versus they’re dealing with being on the autism spectrum.

Nikole: Yeah. That’s a great question, and I think there is a big overlap between those two. So social anxiety can certainly exist on its own, but a lot of people who are autistic are also socially anxious Really what we have to look at when differentiating those two things is, are there the diagnostic criteria of autism also at play, or is this just solely an anxiety disorder?

In that sense, we really have to look at how is this person intuitively understanding what the social expectations are. Are they able to understand non-verbal communication? Are they able to have relationships perhaps with people that they do feel comfortable with, that they’re able to maintain over time, or are they struggling to make any relationship at all last for any duration of time?

So we really have to dig into then what is the criteria for each and are they met or not.

Carrie: Yeah, I think that’s a good distinction about relationship longevity. You talked a little bit about masking and about people struggling throughout the lifespan, but kind of getting by. Can you tell us a little bit more about that?

Nikole: Yeah, for sure. Masking is really when someone adapts their behavior to match the social expectations around them. Obviously, we all do this to some extent. It’s a normal part of socialization throughout your growing up years, and even in adulthood in different social contexts, like I’m not gonna go and talk to my boss the same way I’m gonna talk to my spouse or my kids or my friend.

So we all adapt how we present ourselves in different situations, but typically, when someone does not have autism, this is experienced more as kind of just an intuitive thing that they know how to do naturally, not something that they have to think about and prepare for and practice and worry about.

Versus when you’re autistic, people are masking for much longer periods of time, much more frequently, and it’s experienced as being very effortful and exhausting. Typically, after masking for a long period of time, these people can feel very tired, fatigued, need a lot of time to recover afterward because their nervous system is literally just exhausted.

And when you do that over a lifetime, it makes it harder to understand who you are and you develop your own self-identity. It makes it harder to develop and maintain relationships because if you’re just trying to fit in and look at what everyone else is doing to determine what’s expected of you and then match that, then it’s hard to develop those deeper lasting relationships because who are you?

Like, where’s the you in that? And so it can ultimately lead to a state of burnout for autistic people, which there’s three elements of burnout. So that includes loss of skills that they previously were able to do, excessive fatigue- And then heightened sensory sensitivities. So sensory sensitivities is one of the criteria in autism, but in burnout, those are extremely even more heightened.

Carrie: Okay. And is this typically like when you might see an adult come into therapy, “I’m not exactly sure what’s going on, but I’m having struggles in my relationships and I’m exhausted all the time trying to fit in or trying to make friends. I’m very anxious,” these types of situations?

Nikole: Absolutely. Those would all be red flags for that to look into that more.

The thing about compensation strategies, you can compensate for a challenge, but that’s not the same thing as not having that challenge in the first place. If you had a broken leg, you could compensate by going in a wheelchair or lugging yourself up the stairs to get up, but that’s not the same thing as being able to walk up the stairs with two good legs.

So if you kind of make that equivalency with autism, you can find ways to study and copy how other people behave, or you can follow scripts in conversation, or you can remind yourself to make eye contact or train yourself to, like, look at someone’s forehead or between their eyes if it’s too uncomfortable for you to make eye contact.

You can hide your stimming behaviors. You can ignore your sensory needs. But all of that takes mental and emotional effort and intentionality, and that’s gonna drain you the more frequently you’re doing that and the more contexts you’re doing that. It’s just gonna leave you feeling really dry and exhausted, and we actually do see in the research that people who are autistic seek therapy at much higher rates than non-autistic people, and that therapists very often feel ill-equipped to serve them because they don’t feel like they have enough training in autism and knowing how to help these type of people.

But obviously, it’s very important that we get better trained because they’re seeking care at higher rates, and they need to better understand how their brain works so that they can create an environment that is conducive to their flourishing instead of just constantly trying to mask and fit in to what the rest of the world expects.

Carrie: Right. Sometimes in certain situations, it may not come upon a person’s awareness until they have a child that is really struggling with school or really struggling in social environments to make friends, and they get assessed. And then the parent says, “Wait a minute. All the questions you’re asking, I dealt with those things as a child,” or, “I still deal with some of those issues.”

And that’s an interesting parallel that can happen for people.

Nikole: Absolutely. Yeah, I see that quite frequently. And then there’s a lot of just discouragement of, “Why didn’t anyone see this for me? Why did it take this long for someone to notice this or to say something?”

Carrie: Like the grief and loss piece of it all.

Like you were well-behaved, so you flew under the radar, and nobody noticed that there were other things going on.

Nikole: Right. Exactly. And how much effort it took to reach the goals that you’ve been able to reach. Why didn’t anyone notice how hard I was working and how it was different?

Carrie: Let’s talk about this overlap of OCD and autism because this is certainly something that I’ve seen more of in addition to like the ADHD.

Sometimes they all are occurring together. That’s a lot to try to untangle, but how do you approach therapy in a way that really like respects their neurodivergence while still addressing the OCD? What kind of adaptations might they need in therapy?

Nikole: I think this really starts out from the very beginning.

If you’re a therapist, I really encourage you to think through like what do you have on your website? What directions do you give people to your office? What do you tell them to expect during that first appointment? Autistic people generally feel more anxious in new environments because they rely heavily on past experience to guide their understanding of what to expect.

So if you don’t have that information, it can be very anxiety-invoking to meet someone new or go to an unfamiliar place alone. And so I really encourage clinicians to be clear and direct when they’re providing directions to their office. Even like having pictures of your office on your website, having like an outline of what you’re gonna cover in the first session.

Is this like a standardized assessment? Is it just an open-ended get to know you? They’ll probably be uncomfortable with that. Or like what should you expect? And then during therapy itself, just being kind and flexible and noticing what seems to make the person uncomfortable, inquiring about their needs, just being sensitive to the fact that like if it’s like the overhead fluorescent lighting, like that might be really sensory overwhelming.

If there’s– everyone’s sensory systems has different needs. So we see a lot of overlap in sensory sensitivities between ADHD, autism, also like even kids with learning disabilities. Finding out what works for them, and does your office meet that? I discourage strong scents of cologne or perfume. Anything that’s strong or overwhelming may not go over well.

It might be fine, but just being sensitive to those things. And then particularly if someone is not making eye contact or struggling to put into practice the things you’re asking them to do, instead of framing that as being oppositional or rigid, really looking at like what’s the function of that? Like digging a little deeper and tell me a little bit more.

How does it feel for you to make eye contact? Feels really overwhelming and effortful, and it’s distracting them from being able to process what you’re doing. I tell clients all the time, “You don’t have to make eye contact. It doesn’t bother me.” So just not taking things like that personally, but understanding that it might come from a different nervous system profile and needs, and that that’s not anything personal.

And then I think for developing a treatment plan, it’s important to look at what’s the function of the behavior, and then is that something that is adaptive or maladaptive in the person’s life? An example might be stimming. You might have a client who’s stimming because it’s sensory soothing for them.

And then you might have… That would be more of an autistic presentation. That’s– you could have a different client that is doing a repetitive behavior, like flicking a light switch a certain number of times because they’re worried that if they don’t, then their mom’s gonna die in a car accident That would be more of an OCD presentation.

So in the first case, we wouldn’t wanna target that as an area for intervention because it’s regulating their nervous system. In the second case, we would want to challenge and target that as a point of intervention because it’s a compulsive behavior that’s reinforcing the OCD cycle. So you really have to look at what is the function of that behavior, where is that coming from?

And it’s tricky when there’s both, ’cause sometimes it’s hard to figure that out. But really asking that question of the client, “Is this something that is soothing to you? Is this something that is because of anxiety?” And making a treatment plan from there.

Carrie: I think what you’re saying, curiosity is really key, is a great thing in our field.

Obviously, we’re taught to make evaluations, and so you have to be careful not to make your evaluations too quickly, and to just be curious about like, “Oh, I wonder what this is about,” and, “Hey, I’ve noticed this pattern with you. I’ve noticed like it’s really hard to make eye contact. What do you think is going on with that?”

And just being more curious about, like you said, why they’re engaging in certain behaviors. What’s the reasoning behind it or the function behind it?

Nikole: Absolutely. And I always find that personally, I like just being direct as well, but you can be direct and kind. But most of my autistic clients really appreciate and would prefer that people are very direct with them.

And if they have a question, just ask that.

Carrie: It’s good to know.

Nikole: If you want someone to follow through on this, explain, “This is exactly what I want you to do and why I think it will be helpful.” Just be direct versus beating around the bush or trying to, like, explain it in a sideways direction. Like, that doesn’t usually work very well because there’s a lot of that non-verbal communication and social emotional, like, reciprocity that gets missed sometimes in that kind of communication.

Versus if you’re direct and straightforward, it’s a lot easier to stay on the same page.

Carrie: Okay. Good. What encouragement would you give to someone who kind of like in a spiritual way they’re feeling like, “Okay, my brain works differently. I don’t feel like I’m relating to God maybe the way that other people are.”

And maybe there’s some shame around that or some discouragement, like it’s impacting their faith in a negative way. How would you address that with someone?

Nikole: God is our creator, and He knows how our life is going to be before even created in our mother’s womb. While I certainly understand and can empathize with the frustration of feeling different or feeling people don’t understand you or that you have to work a lot harder than neurotypical people do to get the same results or make the same progress.

I don’t think he makes mistakes, and I also don’t think he wastes their pain. So I would encourage them to pray and bring that to the Lord, and also to learn more about autism and how it impacts people, because I think a lot of times some of the internalized messages that people have about is where that shame comes from is because of misunderstanding how their nervous system works, ’cause they never had an explanation.

And so it just became a character flaw or a fault that got internalized. And when they have a proper understanding of how their brain works, then it’s no longer a character flaw. It’s just A reality of life. And then there’s something they can do about it. If you’re highly sensitive to certain sounds or lights, you can put different light bulbs in your house, or you can wear noise-canceling headphones, or you can plan your social life so that you have recovery time after a big social outing.

Or you don’t have to go to public concerts where there’s tons of people and noise and smells and overwhelming things. So it just allows you to have more control over your environment in a way that lets you engage with people and have those close relationships in a more comfortable and consistent way with how you experience the world.

Carrie: Right. It’s really about navigating some of these compensatory-type strategies as far as, like, therapy goes, trying to figure out what’s gonna work to have your nervous system be at a less heightened level. Is that a good way to say it?

Nikole: Yeah. Yeah. Absolutely. I don’t think there’s any reason why someone who’s autistic can’t be just as close to the Lord as someone with some other struggle or with no mental health or developmental struggles.

Again, I think it’s understandable why people feel anxious and frustrated and all of those things. But having a better understanding of how their brain works, again, I think will help eliminate some of that internalized shame, and hopefully give them some new handholds to move forward. And just like with anything else, we have to depend on the Lord for our strength, regardless of whatever difficulties we face in life.

Carrie: Yeah, I mean, I was just thinking too, as you were talking about that, like, how we really have an opportunity in the church to be more neurodivergent-friendly, that I think a lot of times we don’t take the opportunity to do that. If you go into a lot of churches, it’s loud. There’s bright lights. That’s kind of the thing nowadays in some contemporary worship settings.

So I could see how that would be really challenging for someone that’s dealing with these sensory sensitivities to just even go into church like that, and they may have to find someplace maybe that’s a little bit smaller or a little bit more low-key or make some of those accommodations like you were talking about, wear earplugs during worship or something.

Nikole: Yeah, and I think it’s definitely a call to action for churches because they’re a wonderful place of connection and hopefully a family of faith and love. But a lot of times, we still have our little, like, cliques at, at church and our friend groups and our small groups and things like that, and then we don’t always notice the people on the outside or that are struggling to make connection or to share or who maybe have a little bit different way of relating that seems a little quirky to us.

That can also make it really hard for people who are autistic to feel a sense of community and connection in those spaces, and there can be a lot of misunderstanding that can come from that. That direct communication style can be interpreted as rude or blunt, or difficulty seeing a situation or a comment from someone else’s point of view can again be misinterpreted.

Even things like body positioning, personal space, eye contact, facial expressions, being able to un-infer meaning from other peoples and how you’re presenting yourself impacts them. Like context matters, and it changes when you’re one-on-one versus in a group, church versus at work. And so even when you have compensatory strategies to mask or to try to accommodate the environment, like those aren’t gonna work in every situation.

And so if you go to a new church, and there’s a different culture there, or you’re new to church in the first place, and you don’t know what’s expected, that’s not gonna necessarily work. And so it can be really frustrating and hard to find community in a situation like that.

Carrie: Yeah, I can definitely see that.

In terms of what you’ve seen, I wanna go back a little bit to the OCD piece. Are there particular themes that OCD latches onto more? Are the OCD themes more relational, I guess, is what I’m asking.

Nikole: Yeah, I think they can be. I’ve seen a lot of that, which makes sense in the context of if you think about ICBT and OCD logic of past experiences when you have been rejected, when you have lost friends and not known why or what you did wrong, it’s really easy to then have a narrative form around, “Well, that could happen again.”

I’ve also seen themes around contamination, particularly when someone has those hypersensitivity to certain textures or feelings or smells where they can have those contamination themes around needing to wash, needing to get rid of anything that feels off or different.

Carrie: My favorite T-shirt doesn’t feel right because I got some kind of smell on it, and now I went somewhere and it was smoky maybe, and now I can’t– it smells like a barbecue joint, and now I can’t- Yeah

get it out of there.

Nikole: Anything like that, or just touch– your hands touch all kinds of stuff like rubber bands and food and needing to feel like you need to wash frequently to get rid of those smell, where most people might not even notice a smell. But if you have a heightened awareness to smell And that’s tricky because it’s not really imaginary.

Like, you are smelling it, you just have a heightened awareness, and so then we’re looking at what are your values? Do you want to have, like, chapped, bleeding hands? Okay, that’s probably not gonna be best for you, so how do we address this from that?

Carrie: So almost hand washing may develop from a texture sensitivity at times.

Is that what you’re saying?

Nikole: Yeah, or olfactory sensitivity, yeah.

Carrie: Mm-hmm. Hmm. That makes a lot of sense, actually. Those overlaps makes a lot of sense. I think this is really great for our listeners, but I know we also have some therapists that listen too that are trying to understand their neurodivergent clients better too, so this…

I’m definitely learning some things here. If someone’s been diagnosed with OCD, and maybe they’ve had some treatment, and they feel like what you’re saying, “Okay, some of this stuff is really resonating with me. I do have some of these sensory sensitivities. I’ve had struggles in my social relationship. I think I might have autism, too,” what is their first step towards, like, getting that diagnosis?

Nikole: I would say it really depends on, just like with ADHD, it really depends on what’s your purpose. Is getting a diagnosis, is it very important to you to have a professional assess you and give you a stamp on a paper that says, “Yes, you are autistic,” or is it more just something you want to explore to have greater self-awareness about yourself and how you understand the world?

Official diagnosis can provide a lot of relief for people, and I’ve known people that really just like, “No, I need to know from a professional.” Can eliminate those labels that might be inaccurate or judgmental. It can give you legal rights for accommodations or support. It can give you more of that gift of non-judgmental self-understanding so that you can kind of view past experiences through a new lens of, rather than self-blame and shame, through this lens of why this might have been more challenging for you throughout your life.

And all those things can be really helpful for understanding yourself, for feeling less emotional distress, and just for giving yourself permission to care and advocate for your sensory needs. But I would say seeking a diagnosis is really a personal decision, and a lot of people choose to just self-identify as autistic, learn about it as much as they can.

They don’t feel like they need an official diagnosis stamped on paper, and I think that’s perfectly appropriate, too. Different clinicians differ on this, but it’s not like there’s medication for autism or something that you can only get access to if you have an official diagnosis. It’s really more about accommodating and meeting those needs and learning how to teach those that you love why you need these things and how to best help.

So I don’t know that a diagnosis is always necessary. I do love the book, Is This Autism?

Carrie: Okay, great.

Nikole: So you can link that in the show notes, but it goes through all the different criteria for autism and how it presents in people who are on that lower support needs end of the spectrum, where they’re– they don’t have intellectual disability, for the most part fairly successful in life, but wondering if they might be autistic.

Maybe they’ve had a child diagnosed, like you mentioned, and just trying to understand what could that look like if there isn’t that intellectual impairment also. It’s a great book. It is not from a Christian perspective. I will say, fair warning, in the autistic community, there’s a lot of overlap with just gender spectrum questions in that whole community, so and I think that’s another area where I would love to see more Christians engaging with and helping people to wrestle through those questions.

Because pretty much anything you find on autism out there from this perspective, and I have not found much from a Christian perspective, will have LGBTQ gender type content as well along with it. So there is some of that in the book, but I think it still has a lot of really, really helpful resources and information that people will find helpful.

Carrie: Yeah. It’s a lot to think about. Even if you’re just listening to this episode, and maybe you have a loved one that you’re trying to understand better or kind of listening because you’re really interested in this overlap, I think there’s a lesson here for all of us to say, “It’s okay for us to have needs.”

And I think sometimes we don’t think it’s okay for us to have needs, especially in our relationships. We think we always have to be kind of the one to sacrifice, or we always have to just go with the flow, don’t make any waves. And I think it’s fine to say… I used to go to these trainings and– or I was involved as helping out with some EMDR trainings, and one of the things that they would say, they would give everyone ahead of time was say, “Please don’t wear strong perfume.”

I think that’s a reasonable request, because if you’re sitting in a training all day and you’re becoming overwhelmed because someone got really happy with the body spray, then that’s a deterrent. I don’t wanna be here smelling that all day. Just small little requests like that I feel like can make a big difference, and we can’t always, obviously, control what other people do.

But just to know, like, it’s okay to say, like, “I need to just stay at home today and not be social because my nervous system is very tired, and I’ve done a lot,” or, “I’ve been around other people a lot.” And to give yourself the freedom to really partner with God in knowing yourself and knowing what you need and knowing how to advocate for your needs in a really healthy way.

I just wanna land the plane and say I think that’s a message for everybody, whether you’re on the autism spectrum or whether you have OCD or whether you have anxiety in social settings. Whatever you’re dealing with, that’s a good thing to note.

Nikole: Yeah. And I think it’s very interesting because I think a lot of the things I’ve said and even, like, encouragement for clinicians, like, all those things are also really helpful for anyone who’s neurotypical.

Carrie: Yes.

Nikole: Be patient, be kind, assume good intentions. If someone is doing something that seems odd to you, there’s probably a reason for it. There’s wonderful clinicians out there, but I think too often we can almost jump on this like, well, anything that seems different to us is bad. And I think that comes from a place of just wanting to have clear boundaries to feel safe.

And I think sometimes we need to push back on that a little bit and go, “No, same does not equal safe.” We can allow differences, and that can make our community that much more vibrant and beautiful. And if we don’t allow for that, then we’re missing the beauty of so many people that could be really wonderful members of our churches and communities if they were given a chance and then given a space where they felt safe enough to contribute and to not feel like they have to just try to blend in.

I think if we can all learn a little more kindness and just allowing that space to exist for people, that would go a long way.

Carrie: Yeah. Huge.