21 minute read
Double Slits, Double Binds
Ben MORSA
“I think I am autistic.” How could an analyst respond to this sort of statement from a patient? On the one hand, analysis is a practice of critical reflection on any statement a person might make about themselves. An analyst might consider: “why are they saying this to me now?” On the other hand, the analyst may feel discomfort or a lack of familiarity with what it means to be autistic. And while an analyst does well to respect the patient’s statement, they would be remiss not to consider the context in which it is said.
Assessing adults to determine whether an autism diagnosis is indicated is a fraught process. Assessment is a less common intervention than therapy—less familiar to the public. It is also a costly process that carries all of the barriers endemic to mental health in the United States. The assessment of autism has also largely focused on assessing children. There are clearer processes for assessing autism in children than in adolescents and adults. Autism assessment is also a specialized skill and there just are not sufficient provid- ers to respond to the patient’s statement that opened this paper. And if they could, the patient may be part of one or more groups that may be under identified in autism assessment practices. For so many reasons, an assessment may not reflect the truth of the patient.
Enter self-diagnosis. Self-diagnosis generally refers to the practice of identifying with the diagnosis of autism or, more broadly, the experiences of autistic people. Sensory sensitivity, differences in social communication, executive functioning challenges, deep interests, and a need for the familiar and predictable are the experiences that bridge self and clinical diagnosis of autism. Autism is a disabling condition—whether one locates this in the autistic individual or adopts a social model of disability that attends to the ways society is built in ways that limit or devalue autistic functioning. The functional impairments an autistic person experiences may qualify them for limited and scarce services and accommodations.
Enter the assessor, whose task is to use (contentiously) agreed-upon diagnostic no- sologies and assessment tools to determine whether the patient will receive a diagnosis and associated services. The reality is that the patient’s statement, “I am autistic” is important to hear because they are linking to a category that may qualify them for scarce, and perhaps life changing, support. But analysis is not the apparatus to answer this question. That falls to assessment. And with the growing number of patients wondering about their own autism, analysis may find value in becoming more curious about assessment.
Enter psychoanalysis, a practice that does not rest on the most obvious solutions or explanations but encourages deeper inquiry to learn something new. Assessment may lead to a diagnosis of autism and even offer an explanation to the patient for what this says about their functioning. Psychoanalysis can hold space for the patient’s consideration of ‘autism’, how it does or does not define them, and the tangled epistemological, ontological, and existential questions autism diagnosis evokes. Put another way, because analysis en- courages the patient to take responsibility for what they say about themselves, it is uniquely positioned to meet the self-diagnosing patient. Analysis can help the patient to understand the context of their identification as autistic, how they relate to the diagnosis, and why it might mean something different to them than it does to the DSM 5 (American Psychiatric Association, 2013). Patients are more than their diagnosis. This paper aims to offer a framework for this dialogue or, at least, render its importance.
To accomplish this, I will introduce the agential realist framework of Karen Barad (2007). This framework will help us to delve into the complexity of a diagnostic / identity category like autism and better understand the opportunities and limitations of psychological assessment. Barad (2007) introduces a process of diffraction as a practice that encounters something new in the interaction of the material and the social. Assessment negotiates the interface between material systems and diagnostic categories. Still an agential-realist perspective, challenges the idea that a psychological assessment reflects the ‘truth’ of the patient. As I will elaborate later, assessment of autism quickly entangles in questions of identity and epistemic authority to define identity.
My study of Barad’s (2007) work leads me to believe that it may be more valuable to become curious about how the interactions between the material objects of the assessment, the assessor, and the subject matter. This would allow us to complicate narrow, reflexive, interpretations of assessment data and notice patterns of interference and diffraction that emerge when we construct apparatuses in attempts to know what is there. This feels familiar to the practice of psychoanalysis, which respects the fraught nature of speaking the truth, especially about oneself or others. Diffracting analysis and psychological assessment is both an application and a deepening of Barad’s framework that helps us to understand the burgeoning ecology of self-diagnosis and self-definition that is autism.
Agential Realism, Apparatuses, And Material-Discursive Interactions
Barad (2007) is a leading theorist in science studies and her work offers a refreshing critique of materialism and post-structuralism. While her focus is on science / social discourse more generally, I feel her tools are useful in this paper’s argument for interaction between psychoanalysis and psychological assessment. Barad (2007) takes on a false binary of the division between scientific / material and social / discursive under the heading of agential-realism. She accomplishes this via critique of the idea of “separateness”—especially the separation between observer / observed, measurement / measured, etc. She argues that separateness is neither an inherent feature of the world, nor a linguistic fiction. This enables an interaction between material and discursive practices and a critical understanding of measurement apparatuses and the boundaries they make. Barad acknowledges post-structural thinkers like Foucault and Butler for exposing the fiction of a separate (and therefore neutral) objective knowledge—perhaps especially of the body, gender, and sexuality. Of course, there is extant critique (feminist, queer, postcolonial, critical race, disability, class, e.g.) that skewers the well-worn fantasy of an objective science that can be divorced from the sociocultural context in which it is produced and practiced. Science can not only observe the natural but exerts power through its authority to define what is natural. The conduit of this power is the performance of scientific practices. In assessment, the power to define a patient is performed through conducting an assessment, reviewing the data, preparing the final report, and delivering feedback—including the answer to the question, “am I autistic?”
Barad (2007) picks up from here to review how post-structuralist thinkers challenge the idea that a social category (like diagnosis) reflects the truth of the person. She adds, though she is not the first to do so (e.g. see Sedgwick, 2003), that post-structuralism can tend toward a paranoid position. It is always eager to reveal how the emperor of science, or any established discipline, wears no clothes and expose the underlying, and socially constructed, conditions of identity and oppression. With respect to autism self/clinical diagnosis, a post-structuralist perspective would rightly critique the problems of autism diagnosis, some of which I introduced in this paper. If autism assessment is so fraught with challenges to arrive at a true diagnosis, then is it any wonder that people and communities would make self-diagnosis a social phenomenon? In recent trainings I have offered, questions inevitably arise about the rapid spread of self-diagnosis and this is often linked to social media, TikTok, and misinformation. Whether a patient is “truly” autistic or is caught up in a collective delusion (unlikely, IMO) of self-diagnosis is less interesting to me than the context in which they make the statement. Let us return to Barad to better understand the importance of context and interaction.
Barad (2007) notes that although positivist science and post-structuralism seem at odds, they share a reflexive bias. They share the common fallacy that categories reflect the truth of something—for positivist science, approved instruments reflect the truth of what is measured and for post-structuralists, identity categories reflect a socially constructed truth. For Barad, both of these fail to account for doings and practices that matter. A patient who says they are autistic may come to learn this through interactions with other autistic people, interactions with social media, interaction with a tattered mental health system where clinical assessment is unreachable for many, and all the horrors of contemporary life. An analyst would be right to consider all of this and to wonder about self-diagnosis as defense, including a defense against those very horrors. But is that all there is?
To complicate interactions between observer / observed, Barad focuses on boundary making practices, measurement apparatuses, and sensory registers often excluded by the optic bias of science and the paranoid eye of poststructuralism. For her, “posthumanism marks the practice of accounting for the boundary-making practices by which the “human” and its others are differentially delineated and defined (Barad, 2007, p.136).” Assessment certainly participates in the boundary-making practices of diagnosis, accommodation, and neurodivergent identification. Similarly, psychoanalysis participates in the boundary-making practices of subjectivity and who counts as an agential subject—even as it contests these possibilities for anyone.
I do not read Barad (2007) as cancelling science any more than she is cancelling post-structuralism. Instead, she proposes we move past looking for apparatuses that reflect truth and toward diffraction. Put another way, we need not discard the material nor the social, psychodynamic and contextual. Instead, we can become curious about how interactions between both reveal surprising insights about the material and the social. In this next section, I will review her concept of diffraction and then propose a diffraction of psychoanalytic and assessment apparatuses, so that we might better understand the many interactions that shape the patient’s statement, “I am autistic.”
Reflection And Diffraction
Barad (2007) also identifies a common, reflexive, bias in both material and social-discursive perspectives. Each of these, seemingly incongruent, discourses rely on reflexivity— either of the experimenter measuring an ob- served phenomenon, or of a theorist that asserts social categories reflect reality. It is easy to identify a reflexive bias in the practice of psychological assessment. Classical psychometric theory relies on the assumption that standardized tasks and activities reveal information about underlying constructs in the patient’s thinking and functioning. Common assessment constructs include intelligence, the various executive functions, theory of mind, social cognition, expressive language, autism, gender, and others. These constructs are not equivalent to scientific constructs like displacement, length, velocity, temperature, concentration, and gravitational force. The latter are much more reliable to measure than the fuzzy and socially embedded constructs in psychological assessment. This means that scores and normative data in psychological assessment amplify the reflexive complications that Barad critiques. There is a higher threshold to trust that they represent something real.
To demonstrate this, I will now review Barad’s (2007) concept of diffraction. But to do so, I must also introduce the reader to the famed double-slit experiment. The double slit experiment, and its variations, offer surprising insights about measurement and complex objects of study. An electron is matter, substance. Yet when one fires electrons through a double-slit apparatus, a diffraction pattern emerges. We might expect the electrons to move directly through the slits—landing directly opposite them. Instead, they form an interference pattern as they diffract through the slits. This is strange because waves behave this way—and electrons are particles after all. Or so we used to think. I encourage the reader to seek out one of the many video demonstrations of this, which help to stoke the imagination. What is important here is that the double slit experiment, and this pattern of diffraction and interference, led to the surprising insight that matter behaves both like a particle and a wave. We thought we were measuring something real but, in fact, could only see a partial truth.
Barad (2007) relies on the double slit experiment to offer ‘diffraction’ as an alternative methodology to ‘reflection.’ Diffraction as methodology is an example of observing something we did not expect. This methodology has the advantage of focusing on the interactions between the material and the social. Of course, rather than using diffraction to draw lines, we might do better to be curious about which tools, positionings, and contexts draw which lines and how. Barad terms this focus on interactions between materiality and social discourse ‘agential-realism’ and applies this methodology through discussion of the apparatus.
Apparatus
Barad’s (2007) agential-realist definition of ‘apparatus’ offers several tools for thinking about assessment and psychoanalytic work with autism. She defines several characteristics of apparatuses. They are material discursive practices rather than mere things. In analysis, the couch or telehealth matter. An assessment is more than just an inert tool of observation. Apparatuses are less these things, but more how they are configured and located in the world. Is the couch narrow or wide, short or long? What bodies find comfort there? Does the patient need to walk up stairs to access it? What price must they pay to lay on the couch? There is much more here but note for now the key themes of interaction, mutual influence, open-system, dynamism, and contingency. Each of these introduces problems in a classical and antiseptic practice of either psychological assessment or psychoanalysis. These problems are also affordances and opportunities for meaningful reconfiguration of self, other, human, and world.
Let us consider two apparatuses of autism assessment: the Autism Diagnostic Observation Schedule—Second Edition (ADOS-2, Lord et al., 2012) and the Monteiro Interview Guidelines for the Diagnosis of Autism Spectrum—Second Edition (MIGDAS-2, Monteiro & Stegall, 2018). Clinicians may have heard that the ADOS-2 is the “gold standard” of autism assessment, but when I completed training with an author of the ADOS-2, she clearly stated it is not a “gold standard” and the ADOS-2 should not be the deciding factor in determining whether to diagnose a patient as autistic and this assessment’s manual offers the same guidance (Lord et al., 2012). Her humble statement affirms that the ADOS2 apparatus does not fully reflect the reality of the patient’s autism, or lack thereof. The assessment manual also advises against using the ADOS-2 as a litmus test for autism.
More context about these assessments would be informative. The ADOS-2 (Lord et al., 2012) is a series of modules, chosen based on the patient’s age and expressive language ability. They can look very different, but they have a common purpose—to create a structured but, hopefully, naturalistic experience where the patient can reveal their autism. Autism is defined as a series of atypicalities and the degree of atypicality for each corresponds to a number. The numbers are compiled into an algorithm and a cutoff score determined. The idea is to observe the patient without them being too aware they are being observed. The observer risks influencing what they observe in their interactions with the patient. This makes administration challenging and, for some assessors, deeply uncomfortable.
Perhaps analysts reading about this register discomfort too. An analyst would rightly question, “how is the patient’s narrative taken into account?” In a strict sense, it is not. The MIGDAS-2 (Monteiro & Stegall, 2018) has a different structure. It is open form, lacks the psychometric qualities of the ADOS-2, and is based on narrative theory. It presents questions or activities to the patient that invite them to share about their interests, their sensitivities, their emotional and relational experiences, and their use of language. It catalogues differences, rather than atypicalities. It invites the patient to knowingly show themselves, rather than subtly inducing them to perform autism. Analysis may do something similar. I review these tests to highlight various problems—if the patient has no voice and is surveilled for their strangeness, how will this impact them? If the patient can simply say all the reasons they feel they are autistic, can we truly believe them? If neither assessment is a true “gold standard” then how do we solve the problem of knowing whether the patient is autistic? Furthermore, how do we learn what it means for them to be autistic?
Let us engage an exercise to reflect on these problems. Is the patient autistic when they begin reflecting on this question in analysis? Are they autistic when they self-diagnose? If psychological assessment and clinical diagnosis affirm self-diagnosis, then what was the cause of the autism? Was the cause a motivation to seek assessment first stoked by self-diagnosis? Would self-diagnosis be a cause? Would the feedback session after an assessment be the effect—or a new and true cause, true because it would then be backed by the scientific authority of the psychologist? At which point in this process would a person truly be autistic?
This is where I believe psychoanalysis has something to offer. The concepts of self, self-definition, and truth are always contested. Simultaneously it values the reflective dialogue and project of meaning-making found in the dance of free-association and interpretation. At its best, psychoanalysis holds the reality of constructs and categories in critical suspension. This is not to deny the reality of autistic disability, but, rather, to interrogate the idea that this is something any other person can define. It offers a space for an autistic person to be curious about themselves as such. In the conclusion of this paper, I will discuss how this psychoanalytic affordance helps us to understand the burgeoning ecology of self-diagnosis and self-definition that is neurodiversity.
Double slits and double binds. In one set of interactions, psychoanalysis is ill-equipped to address certain material realities of autistic life. Here, assessment is a different apparatus. Its situation in a field of scientific and diagnostic authority allows it to make the boundary between human and autistic and interact with the material reality of an autistic person in ways psychoanalysis cannot. In contrast, although assessment may offer more material affordances for clinical practice, it is prone to its own habits of mind and imperfect boundary making practices. Autism assessment enacts specific boundary-making practices around subjectivity and, in my view, has much to gain in diffraction with psychoanalysis. Specifically, an analyst can be with a patient while they negotiate these interactions and support them to deepen their awareness of the context in which they (or an assessor) state the patient is autistic.
A Burgeoning Ecology
It is no accident that clinical signifiers regularly compose definitions of autism and serve as the primary objects in conversations about neurodiversity. Clinical constructs, and their check-listed symptoms, serve a gatekeeping function for social services and disability classification. The construction of these diagnoses matters because it differentially impacts the material wellbeing of neurodivergent people. Because diagnostic systems also apportion money and compulsory participation in capitalist labor markets, they call upon designated professionals (primarily psychologists) to enact the authority of defining who meets diagnostic criteria and who is functionally impaired enough to receive support. Psychologists use the practice of assessment to render individuals in the eyes of social systems that matter. Assessors are in a position to do this, analysts are not. This is what assessment can offer analysis.
In this diffraction, analysis can also offer something to assessment. The phrase, “I am autistic” makes (or should make, IMO) the analyst curious. Intrapsychic splits, repression, projection, the holding environment, the attachment system, and the relational field all complicate the idea that there is an ‘I’ to be or a subject who could truthfully say, “I am autistic.” It piques analytic curiosity. At best, the analyst approach- es the patient’s claim with a spirit of curiosity and an openness to the patient’s associations to autism—neither rejected nor accepted outright but held in an open tension.
This tension might reveal diffracting dynamics that accentuate the complexity of the statement “I am autistic.” Trauma, depression, family dynamics, flows of (mis)information, the trials of life, and garden variety identifications and defenses all seem relevant contextual factors that analysts are well-positioned to consider. Each may, or may not, drive the patient to say they are autistic. Perhaps more importantly, analytic apparatuses may help the patient understand what it means for them to be autistic in deeper and more contextual ways than the DSM-5. Assessment will weigh in on the patient’s statement—but largely in terms of gathering evidence for functional impairment—a breakdown of the interaction between individual and environment. And the conclusion may have a direct material impact on the patient as well as epistemological and ontological implications for their experience of knowing (or not knowing) their being.
Psychoanalysis has the potential to hold space for the fact that autism—like any category—is in suspension. Changing perspectives of what autism is, critiques of the autism status quo (applied behavioral analysis, and the pathology model of autism), the errors of assessment tools (and assessors), a lack of consensus on the assessment process for adolescents and adults, the financial barriers to accessing quality assessment, and the systemic barriers that constipate the pipeline to train more assessors all speak to the material reality that if objective diagnosis (and therefore assignation of autism as signifier of identity) were possible, few would be able to access it.
In closing, I want to return to the assertion that self-diagnosis is a kind of fad or collective defense. I mention this because some version of this statement / question inevitably appears in trainings and supervision I lead. Typically, people code the burgeoning ecol- ogy of self-diagnosis and self-representation of autism in social media as collective defense against the trauma of COVID, youthful refusal to grow up, or a delusional defense transmitted through social media- like a virus or a dangerous refusal to wear a mask. This context is certainly relevant to consider, but to say it reflects a reality that the patient’s statement is not true may be misguided.
Consider the adolescent who does not turn work in on time, refuses to attend school, and has taken to always wearing noise-cancelling headphones. Is this merely an example of how “kids these days” refuse the responsibility and hardship of growing up? Then again, can we blame them? The world we are leaving them is burning, their innocence has been stolen, and we feel helpless to repair that. I take for granted that analysts would recognize the dangers of responding to the patient’s statement with the reply, “no you are not,” perhaps especially an adolescent patient, particularly if followed by adult rejoinders to pull themselves up by their bootstraps.
The statement, “I am autistic” is a kind of constitutive negation. When a patient identifies themselves as an autistic subject, this identification also rests on a negation—they are not neurotypical, they are not functioning in the world, they are not supported, they are not normal, they are not what is expected of them, they are not understood. Conversely, when an autism diagnosis is assigned to them, they may not know what this says about them. In a first session with a patient, I said I was just getting to know them and asked them to tell me about themselves. They replied by saying they had been diagnosed with autism, c-PTSD, and alexithymia. They received these diagnoses in a formal assessment and added that despite feeling they were true, they had little idea of what this meant to them.
For various reasons we chose not to work together. In this situation, I often offer psychoeducation about the therapeutic alliance and its central role in the outcome of a treatment—oftentimes more than any specific orientation or brand of therapy. They said this was hopeful and disheartening. Hopeful because it meant they could decide. Disheartening because only they could decide. Is this not a truth patients encounter in analysis?
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi. org/10.1176/appi.books.9780890425596
Barad, K. (2007). Meeting the universe halfway: Quantum physics and the entanglement of matter and meaning (2nd Edition). Duke University Press. DOI https://doi. org/10.1215/9780822388128
Lord, C., Rutter, M, DiLavore, P., Risi, S., Gotham, K, Bishop, S. (2012). Autism Diagnostic Observation Schedule Manual (2nd Edition) [ADOS-2 Manual]. Western Psychological Services.
Monteiro, M. J. & Stegall, S. (2018). Monteiro Interview Guidelines for Diagnosing the Autism Spectrum, Second Edition: A Sensory-Based Approach [MIGDAS-2 Manual]. Western Psychological Services.
Sedgwick, E., K. (2003). Touching Feeling: Affect, Pedagogy, Performativity. Duke University Press. DOI https://doi. org/10.1215/9780822384786
Contributors
Benjamin Morsa, PsyD is a clinical psychologist and psychoanalytic practitioner in Oakland, CA. He founded the group practice Tide Pools, a psychological corporation, a generalist practice that specializes in psychoanalytic work with gender diverse and neurodivergent patients. He offers psychotherapy, psychological assessment, consultation, and training. His clinical and scholarly interests include interdisciplinary approaches to psychoanalysis, the Rorschach, forensic educational assessment, autism, neurodevelopmental differences, gender, sex and sexuality, mycology, and the philosophy of science. He has taught graduate and postgraduate students at psychodynamic and psychoanalytic programs in the Bay. He is also a musician and all-around polymath.
Ben Stephens, photographer, https://www.benstephensphotography.com
