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In this paper, we describe the case of John (not his real name), a man with co-occurring learning disability, autism and alcohol use disorder. People with intellectual disability struggle to understand new or complex information, learn new skills and live independently (Department of Health, 2001). A total of 2 per cent of the UK population are learning disabled (Emerson et al. , 2012). Autism causes difficulties with social interaction, restrictive and repetitive behaviour, and communication, and also restricts independent living (World Health Organisation, 1992). It affects 1.1 per cent of the UK population (Brugha et al. , 2012). Alcohol dependants prioritise alcohol over other activities, often causing self-neglect (World Health Organisation, 1992). In total, 6.5 per cent of the English population show symptoms of alcoholism (Lifestyle Statistics, 2013).
While co-occurring autism, alcohol use disorder and intellectual disability are rare, they challenge traditional services because a standard treatment pathway does not exist. The UK's National Institute for Health and Care Excellence (NICE, 2011) guides clinicians on treatments for alcohol-use disorder, but overlooks people with co-occurring intellectual disability and autism. Researchers have reviewed treatments for people with an intellectual disability who suffer from an alcohol use disorder (e.g. Burgard et al. , 2000; Degenhardt, 2000; Kerr et al. , 2013), but not for the additional comorbidity of autism. The lack of research into autism and alcoholism has been highlighted by the autistic community (Hendrickx and Tinsley, 2008).
For treating John, we grappled numerous legal complexities including the necessity of Mental Capacity Act 2005 assessments, the implications of the adult autism strategy for England (Department of Health, 2010), the limitations of the Mental Health Act 2007, the requirements of the Equality Act 2010 to make "reasonable adjustments" and the tension between our duty of care and John's right to take risks.
Supporting choice and personal control are core principles of working with people who have an intellectual disability (Department of Health, 2001). However, our experience with the current case suggests an uncritical, blanket approach to these core values - unfettered client autonomy - may not always be client centred and can sometimes be potentially life threatening. Client-centred care must take account of fluctuations in capacity and not, when appropriate and indicated, shy away from considering restrictions on service...