Summer 2025 Issue

Treating Suicidal Ideation Among Autistic People
By Miriam Edelman, MPA, MSSW
Social Work Today
Vol. 25 No. 3 P. 14

Social workers are attempting to reduce the rate of suicidal ideation among this population.

Autistic people (AP) are at a much higher risk of suicidal ideation and suicide. They struggle to live in a world not built for them.1 As Debbie Miller, an autistic research methodologist, writes on Linked-In, “It is NOT being autistic that makes us suicidal. It is societal contexts that prevent us from being true to […] expressing who we are that accomplishes that.” How can social workers help this population?

Suicide reportedly is the second-biggest cause of death for AP without a learning disability.2,3 While AP comprise approximately 1% of the population, they account for 11% of deaths by suicide.2 AP harbor more suicidal ideation than the general population. They have a lifetime 66% experience of suicidal ideation.4 They have up to a seven-times greater chance than nonautistic people attempting suicide and a larger rate of suicide attempts resulting in death.5,6 Autistic children are 28-times more likely to have suicidal ideation or attempt suicide.2 While 42% of autistic adults reported suicidal ideation, 18% reported suicide attempts.7 These percentages are much higher than the following equivalent percents for nonautistic people: 4.8% (suicidal ideation) and 0.7% (suicide attempts). Reasons for Suicidal Behavior Among Autistic Individuals AP are more likely to die by suicide.6 Presumably owing in part to autistic symptoms, they can be more likely to experience exclusion, unemployment, poor physical health, and social problems.5 Up to approximately 85% of AP are unemployed.8 These negative experiences and the need to mask to fit in with the community cause them to have a greater chance of acquiring mental health problems.6 If those conditions are not treated, individuals could be more likely to die by suicide. Due to their autism-related social and communication issues, they can be isolated and have little to no support, making them more likely to be at risk for suicide. AP’s cognitive inflexibility is also a risk factor for suicide. AP can ruminate, becoming stuck on negative feelings.7 Many people, especially women, are not diagnosed with autism until adulthood.6 Such a late diagnosis can affect quality of life and cause mental health issues. It is tied to a larger chance of suicidal thoughts.6 Other risk factors for suicide-related behavior among AP include depression, challenges using coping skills when sad, experience of trauma or abuse, impulsivity, problems with executive functioning and emotional regulation, higher cognitive ability, unemployment and underemployment, gender dysphoria, bullying, eating disorders, and camouflaging/masking.7,9 Manifestations of Suicidality in AP Suicidality can appear differently in AP than in the general population.6 According to Lisa Morgan, founder and cochair of the Autism and Suicide Prevention Workgroup, autistic individuals with a high IQ are more likely to experience suicidal thoughts.10 Compared with others, AP have more perseverance, repeated suicidal thoughts, and a larger chance of trying to die by suicide absent a plan.6 A decreased fear of death, but not tolerance of pain, is correlated with more suicide attempts by autistic adults.11

Although women have a smaller chance of dying by suicide than men in the general public, autistic females are 13-times more likely than nonautistic women to take their lives.6 Autistic women without learning problems have the largest likelihood of killing themselves.6 They are also more likely than autistic men to try to die by suicide and to conduct self-harm, although autistic men and women are similar regarding suicidal ideation.5

AP might have trouble identifying and/or recognizing emotions, but they may exhibit suicide warning signs.12-14 Often, when they have suicidal thoughts, they behave differently than they usually would. Warning signs include quick or increased withdrawal, lack of words to discuss distress, current trauma, an increase in amount or severity of self-harm, and increased symptoms of anxiety and/or depression. Additional signs are a new concentration regarding suicide/death, perseverative suicidal feelings, suicidal plans, lack of hope, comments regarding no purpose in life/no reason for living, sleeping issues, feeling trapped, rage/seeking revenge, taking risky actions, major mood changes, more substance use, giving away special objects, wanting long-term care for pets, and more.14,15 Frequently, AP who are at “imminent risk of suicidal behavior” have at least two warning signs.14

Autism can mask suicide warning signs.16 For example, doctors can mischaracterize self-harm, a suicide warning sign for the GP, as a symptom of autism.

Protective Factors
Protective factors that decrease the chance of SA and suicides in the general population are not always as effective for AP.11,17 Morgan remarks that many protective factors for the GP population are risk factors for AP. A 2024 study discussed the lack of literature about protective factors regarding suicidal feelings and actions for AP.11

Higher IQ and more education are protective factors for the general public, but not for AP.11 While rates of suicide attempts decline as the level of education increases for people without autism, AP with vocational or college education did not have lower suicide attempt rates than autistic individuals with a basic education.18 Kairi Kõlves, a suicide prevention professional, remarks that more cognitive functioning can result in a better understanding of how to take one’s life.19 She says, “A higher educational level may contribute to a greater awareness of their differences [from others], which may result in alienation from family and society at large and bring further social anxiety and isolation.”19

Being married or living with someone and working are more protective for nonautistic people than for AP.11 For the general public, people who are not married or living with someone have higher suicide rates. In contrast, for AP, marrying or cohabiting does not affect suicide rates.

Employment is also less of a protective factor for AP than for others. Employment might not help autistic individuals because they may be overqualified for their position, may work just part-time, and may be more likely to be the victim of workplace bullying.20 Unemployed AP have the highest rates of suicide attempts.18 Unemployment, which is experienced much more often among AP than the general population, is associated with a 16-times larger rate of dying by suicide. Not working due to a disability increases the risk of taking one’s life.

According to the American Foundation for Suicide Prevention, protective factors include “access to mental health care and being proactive about mental health,” “feeling connected to family and community support,” “problem-solving and coping skills,” “limited access to lethal means,” and “cultural and religious beliefs that encourage connecting and help-seeking discourage suicidal behavior or create a strong sense of purpose or self-esteem.”21

However, some of these factors might not work for AP. Autistic adults use mental health care more often than nonautistic adults but have unmet mental health needs.22 Many providers have not been trained about autism. They may use treatments that might not accommodate their clients. AP can have trouble navigating the health care system. Many autistic individuals might not feel connected to family because they often are lonely and isolated.23

More research could be completed regarding protective factors for AP.7 An article, “Updated Systematic Review of Suicide in Autism: 2018-2024,” states that while 3.8% of studies were about these protective factors, 72.5% focused on risk factors.9 Studies show an association between autistic adults’ feelings of having supportive social ties and little suicidal behavior.7 Connections with family and community support can help.21

Another study reports that dog ownership could help decrease suicide-related behaviors among autistic individuals.24 Major reasons why dog owners would not die by suicide involve needing to take care of their animal and receiving their dog’s affection. However, some are allergic to, are afraid of, cannot afford, and/or otherwise do not want a dog. Other pets could be protective factors, as animals need their human owners. Another protective factor could be indoor living plants, which need humans to water them and can reduce stress levels.25

Other potential protective factors exist. One such factor is “validation of experience,” which is recognizing and accepting people’s lived experience and thoughts as worthwhile.11,26 Validation does not always include agreement. Other protective factors include resilience, receiving mental health care from clinicians who were trained in helping AP, life skills, and beliefs in the wrongfulness of killing oneself. Another potential factor could be a role in one’s community that would give purpose and meaning, and that involves the person being needed. Although positive feelings about oneself can be a protective factor, it can be difficult for AP to have a positive self-image if they have frequently been excluded and marginalized. Another protective factor could be fear of negative consequences of a nonfatal suicide attempt. Failed attempts to end one’s life could cause major physical injuries, which could worsen the person’s life.

Suicide Prevention Treatment
According to Morgan, there are no best practices to treat autistic clients who think of suicide. She suggests using individualized coping skills and distraction strategies. Mental health professionals should try to help the client move past his/her suicidal thoughts and/or behavior.

Methods to treat suicidal ideation of an autistic client include the following:

• Believing what the client says. Failure to do so continues AP not being believed.27 The client’s feelings and thoughts should be taken seriously. Social workers need to remember the core social work principle that the client is the expert. They should not believe that their autistic client is not in a crisis just because they can seem fine.28 The client might experience alexithymia, meaning they might not understand or describe their emotions. Social workers should realize that the client might show emotions that are opposite to what people usually have in a crisis.29 For example, the client might laugh when they contemplate suicide.

• Using social work profession’s language. Morgan suggests that social workers can say “I see you’re struggling” or ask “Are you struggling?” Then, the social workers and their clients can collaboratively discuss what the client experiences.

• Validating the client’s experience.

• Never downplaying what the client is going through.

• Not getting irritated with clients’ perseveration.

• Creating an autism-adapted safety plan with the client.30,31 Before a crisis, an individual who might conduct self-harm or take their life should create a safety plan.30 The plan, written in the person’s own words, lists steps a person can take to be safe. Safety plans can use simple language, be clear, and include visual aids.11

• Having the client create a “Reasons for Living” document.32

• Asking clear questions.29

• Permitting the client more time to talk.

• Using logical, not emotional, words.

• Describing positive coping skills and explaining their usefulness.

• Keeping in regular contact with the client via phone and email.

• Holding extra therapy sessions if possible.

• Conducting a wellness check and/or calling 911 if seriously concerned about the client’s well-being.

• Encouraging the client to participate in activities that would bring them joy and meaning.

• Encouraging the client to join a support group of other AP who experience suicidal thoughts.

• Connecting the client with social groups of AP.

• Encouraging the client to join communities.

Another way of preventing suicidal ideation among AP could involve connecting them with people who help AP secure employment. Connecting people with resources is a job responsibility of some social workers. Morgan says that if the employer understands autism, then an autistic worker could feel a connection and have purpose.

Workplaces might be problematic for AP. Autistic individuals have a greater chance of being bullied at home, school, and workplace.33 Workplace bullying causes the loss of jobs and high unemployment rates among AP. Autistic individuals are also fired due to autism-related behavior, not bad performance.34 Reasons for termination may include “taking instructions literally” and “[a]sking ‘too many’ questions.”35

Evidence-based suicide prevention treatment interventions were designed for nonautistic people.11 Successful suicide prevention with the general public is not always suitable for AP36:

• 988 suicide and crisis lifeline: Many AP do not call hotlines because they feel that their concerns are not taken seriously or understood.37,38 Hotlines can cause unintentional harm by well-meaning professionals.28 As of 2022, suicide hotline employees have training in mental health, not necessarily in autism.39 Hotlines could benefit from Morgan’s guide, entitled “Crisis Supports for the Autism Community.”29 Autistic clients could refer to the “988 Information for the Autism Community” resource by Morgan et al.40

• Cognitive behavioral therapy (CBT): This method, viewed as the gold standard, which involves challenging negative views, might not work for AP.41 Some people who experience suicidal thoughts would like to end their lives because they feel hopeless. Their major negative thought could be that no one wants them. It would be difficult for them to change that thinking through CBT, because in their lived experience, they have been excluded and marginalized.

• Feeling gratitude: This technique, which helps increase positive emotions and decrease the chances of depressive symptoms that lead to suicide, might not work for AP.42 It can be difficult for AP to feel gratitude and keep gratitude journals when they may never have the life that they thought they would have. Often, they cannot live to their full potential because of the unaccepting world.

Other methods that usually do not work for AP include the following:

• Talking about successful AP. According to Morgan, autistic individuals might think, “Others are successful, but I can’t succeed.” This method might backfire, as it could make the autistic client feel worse.

• Saying statements, such as “you are brave” and “you can get through this.”28 Many AP do not understand that communication.

• Discussing the value of an autistic client’s life. Morgan says AP’s own lived experience often involves exclusion and marginalization. Their life is truer for them than someone saying something otherwise.

• Using social work’s strengths-based practice, highlighting positive attributes of the client and the client’s life.43 This tactic might fail because an autistic client can believe that their strengths and positive attributes have not helped.

Mental health clinicians might think that their undiagnosed client has autism and that autism is a contributing factor to the client’s suicidal thoughts and behavior. Morgan suggests that social workers discuss these thoughts with the client. Many people learn that they are likely autistic this way.

Mental health clinicians can receive training regarding autism and suicide.

Social workers must do their best to reduce suicides among autistic clients. AP are worth it and can contribute to the world in ways others do not.

— Native Washingtonian Miriam Edelman, MPA, MSSW, is a Washington, D.C.,-based policy professional. Her experience includes policy work for both the Senate and House of Representatives. Edelman’s undergraduate degree is from Barnard College, Columbia University, with majors in political science and urban studies and a concentration in history. She has a Master of Public Administration from Cornell University, where she was inducted into Pi Alpha, the national honorary society for public administration, and was awarded the Cornell-wide Distinguished Leadership Award. She also has a Master of Science in Social Work (focusing on policy) from Columbia University. She is a commissioner of the DC Commission on Persons with Disabilities. Edelman aims to continue her career in public service. She is especially interested in democracy, civic education, District of Columbia autonomy, diversity, health policy, women’s issues, and disabilities.

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