13 minute read
Where We Stand With Autism
Brian E. SMITH
An action so often understands how to disguise itself as a passive experience. —Freud
For some decades now, speakers on autism have observed a surge in diagnoses that some have called an epidemic. Once thought of as among the rarest and most severe of clinical problems, affecting no more than one-to-four out of ten thousand, estimates of prevalence in some places have reached as high as one out of forty-four children, with increases looking asymptotic. Autism has commanded attention, and deserves it, not least because no other diagnostic form has undergone such staggering change in perceived quantity and quality—from almost non-existent to seemingly everywhere, from gravest pathology to a wide array of phenomena. It seems as if we are trying to work something out.
Epidemiologists, to whom we ordinarily might turn in such a situation, insist that they have little to offer. They are clear that their methods do not and cannot answer a question some pose, even as others object to its premises: whether the growth in autism diagnoses reflects true change, or is only a function of altered practices and social conditions. The conditions they identify are: more numerous and more liberal diagnostic definitions, diagnostic substitution by autism for other diagnoses like intellectual disability, increased awareness of autism among professional and lay people, and advocacy to diagnose as early as possible. The most this line of work can conclude is that the changes better cover the involved population, even as it can’t quite shed a suspicion some have that the language of autism has come to describe people who, for lack of a better way to put it, might not be autistic. But it cannot tell us whether there are more autistic people than there used to be, or even whether—to put it a bit existentially— there is more autism than there used to be.
Without helpful understanding, many fall back on intuition, and autism affords expression of a common one: that trends in mental illness or their diagnosis express shared or cultural psychological preoccupations. Over time these intuitions have tracked trends in the appearance of things like depression, attention-deficit / hyperactivity disorder, obsessive character, multiple personality and dissociative identity disorders, and now autism spectrum diagnoses. Other problems preoccupy other times and places. Here the thought is that something in the culture has been making us more autistic, and the intuition seeks to link shifts in diagnosis to seeming autistic phenomena and concurrent cultural trends. The need for links can feel so great that some who cannot tolerate uncertainty cobble together whatever they can find, and insist on its value even when discredited.
Meanwhile the phenomena have long since burst past the conceptual apparatus seeking to meet them, manifesting with such diversity that even the most circumspect generalization can feel misplaced, even dangerous. Thus the wisdom in the familiar autism rights aphorism, “If you’ve met one person with autism, you’ve met one person with autism.” In this field, great caution is good counsel. There is no overestimating the value of what is often felt to be at stake in conversations about autism; no overstating the strength of conviction, the pressure to believe and be believed; and too often, no mistaking the impulses toward retaliation. People get fundamentalist at autism.
Since so much is at stake, any step risks harm. For my part, I acknowledge the perhaps inevitable harm this writing may cause. I apologize for this harm. I hope you will simply discard whatever you find unhelpful. I will be happy if, by sharing what I think I see, I can shed even a little light on a situation that is so clearly unclear. Perhaps it is too much to hope that this brief communication might contribute in some way to the dignity and satisfaction of people with autism and those who love them.
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Overlapping the same decades as the changes in autism, psychoanalysis famously declined in the West, its power largely assumed by organic psychiatry and behavioral psychology. One form this took was replacing what little was said about autism—as in Margaret Mahler’s theory of normal early autism, and the so-called refrigerator mother theory—with beliefs in biogenic autism, that is, that autism is an expression of organic factors. Mahler, in a relatively early part of her career, crafted a theory of normal infantile autism as the earliest phase in her program of separation-and-individuation, a phase characterized by “lack of awareness of a mothering agent.” She later recanted. The refrigerator mother theory is a popular way of referring to a formulation of psychogenic autism that emerged in the decades after Leo Kanner, in his foundational work on autism, claimed to perceive emotional coldness in the parents, particularly the mothers of the autistic children he observed. The theory reduces etiology to a consequence of the supposed coldness, and was, in my view, part of a larger trend, still with us, that literalizes the psychoanalytic emphasis on childhood and reduces it to a crude psychogenesis that always links clinical problems to deficits in parenting. Some theories are less brutal and less prone to caricature than the so-called refrigerator mother theory. For one, a long tradition of workers, largely European, have emphasized that they treat only psychogenic autism or its psychological facets, leaving to organic origin whatever space it occupies. Indeed, many contemporary psychoanalysts seem to feel little conflict in recognizing as organic the origins of the autism of people they treat, while others simply keep etiology and treatment separate enough to offer their help without getting drawn into questions of origin.
The point is not the origin, but rather that psychogenic theories were once more viable, perhaps even hegemonic, and have largely been replaced by organic accounts. The implication, often unstated, is that progress has been made—we once were foolish, or dogmatic, or cruel, but now we understand things better and behave with more compassion. This seems to be true, but it is also not the point. The point is that the possibilities for thinking, talking, and belief have changed. In seemingly sensible conversations, people have a hard time appearing or even feeling reasonable in voicing a psychogenic autism. Thinking and talking about autism are now structured this way.
Or put another way, autism is now one of the only ways left to reliably do something that used to be central to psychoanalysis: being scandalous. It is hard to be scandalous with the things psychoanalysis used to be scandalous about—things like incest, atheism, toileting, psychological explanations for evil. Around none of them can a psychoanalyst stir scandal as reliably as uttering something felt to communicate a parent’s even unwitting hand in their child’s autism. In many settings, to wonder such a thing is a thought-crime. It is preferable and less seemingly unreasonable to wonder if a vaccine or an unknown environmental toxin is somehow involved. No doubt the shift from clinical psychoanalysis to organic psychiatry and behavioral psychology expresses changes in the possibilities for belief about a great many things, in and out of the domains traditional to psychiatry and psychology. Across the board—the story goes—it is relatively more difficult than it used to be to seem or feel reasonable in voicing a psychogenic theory of anything. Often this is because psychogenesis is felt to imply blame, and the theory seems cruel.
This may be the main reason why our interest in working on the theory of psychogenesis has so atrophied—because many have decided that it must mean trauma, by which they usually mean abuse or neglect, even indifference, and usually picture a blameworthy party. If we can’t imagine a person or entity actively or passively harming someone—by commission or omission—we have trouble imagining a psychological origin to a psychological problem. This has impoverished our theories of pathogenesis, and has left us, when we want to try to explain something for which such a personified trauma does not seem to fit, with little recourse but to fall back on innateness, which fast becomes biogenesis; we then look for organic correlates of psychological phenomena and believe in them as holding truth when we find them. All the while we carry an at least latent—often enough manifest—moral memory of the harm that some theories of psychogenesis have caused. Taken together we have in effect become phobic of psychogenesis. It might be helpful to remember that psychoanalysis used to know how to think psychogenesis without recourse to blame or its disavowal, or even necessarily to an external precipitant. Naturally such an idea would be a little like internal psychological conflict in its relative independence from outside factors. And yet we might still notice a pathogenic moment, which would be more like a psychological accident—something that is nobody’s fault, but still happened, causing injury, with consequences.
After all, the history of the disillusion with psychoanalysis is nothing if not a reckoning of who to blame and why. Psychoanalysts so clearly have on their minds the blood on their hands: of women, people of color, queers, the poor, the differently abled, non-physicians, patients unhelped or frankly harmed by dogmatic treatments. There are others. Autistic people and those who love them lay claim to special status in this group on account of the great change in the appearance of quantity and quality of autism in recent decades. This point cannot be overemphasized—that out of fields in which autism shares so much with other things, it stands unique because nothing else has undergone change quite like it. This uniqueness calls for special understanding.
The context for that uniqueness is shifting zeal—for a time, a lot of people believed that psychoanalysis could do anything. Some still do. And then, for a time, a lot of people believed psychoanalysis wasn’t good for much at all. Some still do. From this perspective, the famous decline of psychoanalysis might have been a welcome relief from the tyrannies of unrelenting zeal. And because the so-called refrigerator mother long has been shorthand for the worst excesses of that zeal, an uncompromising biologism persists for many as a cherished corrective of the damage that zeal did and safeguard against repeated error.
In fact, the fruits of biologism (indeed, of any essentialism) go further: it can be reassuring when we have doubts about ourselves; it shields us from blame; it is relatively easy to understand, and therefore to use in building consensus; and, perhaps most importantly, it is a bedrock of claims for safety, dignity, rights, and justice. Because claims of innateness pull on our sympathy, we use them to fend each other off—interpersonally, politically, clinically, even intrapsychically. And yet, however important these claims may be from the perspective of safety, they may be failing to tell us enough about what else we might be doing to ourselves and each other when we believe and disbelieve things. After all, belief is countertransference too.
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Many authorities on autism describe its essence as a difference or disorder of belief, and of a specific kind of belief at that—the belief that other people believe things. They often state this using the familiar psychological constructs of theory of mind, mentalization, and metacognition. By this they are describing their own picture of an autistic person’s sense of the inside of another person, specifically that person’s mind. Perhaps importantly, there are four minds in this scenario: (1) the authority imagining (2) the autist knowing less about (3) someone’s mind than (4) another person whom the authority considers normal knows about that mind. Clearly this involves at least two stereotypes: the autist and the normal.
Whatever our ideas of the essence of autism, if there is any, there can be little doubt that sometime in the last quarter of the twentieth century, the uses of those ideas shifted dramatically among a very large group—at least the West, possibly the species. In my view, the shift involved unconscious psychological group work. This is a logic fa- miliar from theories of group processes, as in group therapy, in which a group’s use of ideas—and in particular a dramatic change in those uses—expresses underlying unconscious group motivation. From this perspective the great shifts in autism were not passive—something that happened to us, like an earthquake—but rather something we did to each other and ourselves, out of complicated conscious and unconscious motivations. The fuller thought is that unconscious group motivations contributed to the constitution of (a perception of) a critical mass of autism in shared awareness. Our task would then be to try to understand what these motivations were and why we chose autism to serve them.
Over time, as so many expressed their doubts about psychoanalysis, some gravitated toward the weakest spot, the place where psychoanalysis most feels its shame and least its courage. They perceived that because of the moral record, it is at autism where psychoanalysts least feel—or least voice—the skepticism necessary for their work. It turns out that the context and the phenomena fit together: the former, disillusion and its consequence, impoverishment of belief; the latter, a social form communicating that people do not believe things. They fit so well that they seem mutually reinforcing. And so we might see the autistic theory of mind as neither difference nor disorder, but rather as identification with this social fact, the fact that certain people do not believe things. There can be little doubt that at least psychoanalysts believe much less, and much less intensely than they used to—that they thinned out the courage of their convictions because they are ashamed of themselves.
Of course expressions of suffering are always invitations for care, and in such exchanges both parties get a chance to grow. If what happened with autism is such an invitation, then it is, in my view, at least twofold. First, the ordinary one that some psychoanalysts have always received and responded to, at times well and at times poorly: to provide analytic therapy to suffering autistic people and those who love them, which analysts go on doing every day. And then a second invitation, perhaps subtler than the first, but whose consequence could be more farreaching: that psychoanalysts dust themselves off and feel something of their old strength, picking up, among other projects, work on the theory of psychogenesis without any necessary reference to the two dominant narratives, biogenesis and blame. This latter interest would call on psychoanalysis to remember itself and its value, which is to say, to surmount its shame. The hope would be the same as with any reparative effort that does not merely become depressive.
Contributors
Brian E. Smith, Ph.D., J.D. is a general and addictions psychologist and psychoanalyst in private practice in New York City. He is Assistant Clinical Professor of Medical Psychology at Columbia University College of Physicians and Surgeons, and is President of the Division on Addictions of the New York State Psychological Association. He has taught and supervised trainees at a number of hospitals, graduate schools, and law schools. A graduate of the Columbia University Center for Psychoanalytic Training & Research, where he is on the faculty, he holds a Ph.D. in clinical psychology from The Derner Institute at Adelphi University, and a law degree from Yale.
Ben Stephens, photographer, https://www.benstephensphotography.com
