Addressing Autistic Mental Health from the First Person

Today's post is by Themistoklis Pantazakos and Gert-Jan Vanaken. Themistoklis (he/him) is an Assistant Professor in Philosophy of Psychiatry at The American College of Greece and an Honorary Research Fellow at University College London. He works on phenomenological psychiatry, focusing on treatment methods that make sense of the point of view of client users and their communities. 

Gert-Jan (he/him) is a post-doctoral researcher at KU Leuven and the University of Antwerp. He works at the intersections of bioethics, disability studies and clinical autism research. His work focuses on developing neurodiversity-affirming autism care practices. Here, they argue that interventions for autism should address autistic mental health directly, and that a first-person approach is key for adapting psychotherapy to the needs of the autistic population. The full article is here, available open access.

Themistoklis Pantazakos

"[R]ight from the start, from the time someone came up with the word ‘autism’, the condition has been judged from the outside, by its appearances, and not from the inside according to how it is experienced." 

- Donna Williams (Autism: An Inside Out Approach)

Autistic people face a mental health crisis that is hard to overstate. Compared to the general population, autistics among us are significantly more likely to experience most major psychiatric disorders, two and three times more in the case of anxiety and depressive disorders respectively. Alarmingly, 31% of the premature deaths of autistics is due to suicide compared to 4% in the general population.

Public perception is often that the problem of autistic people is autism itself. This view is shared with the dominant, medical approach to autism, which conceptualizes it as a set of neurological and psychological dysfunctions within the individual. Correspondingly, interventions for autism most often aim at making the person less autistic. Particularly so, behavioral interventions, which constitute an overwhelming majority of the interventions publicly funded and undertaken for autism, are purposed to eradicate ‘problematic’, autistic behaviors and establish typical, pro-social ones. 

Gert-Jan Vanaken

First, our paper highlights that this view is not well-supported by the evidence. If autistic ‘symptom’ severity was indeed to blame for the mental health crisis, we would expect to see a positive correlation between the degree of autistic characteristics and mental health problems, which cannot be found at this point. In line with a social model of disability and with claims made by autistic self-advocates, we cite preliminary evidence pointing to a correlation between the wellbeing of autistic individuals and the perceived quality of support and the degree of social acceptance they enjoy. We conclude that what is necessary to address the crisis is not yet more ‘symptom’-targeting interventions and attempted normalization of autistic individuals but approaches that directly aim to improve mental health instead.

Second, we argue that contemporary psychotherapy is ideally posed to fill this lacuna in the autistic mental healthcare landscape if it overcomes a major contradiction. On the one hand, to be neurodiversity-affirming, psychotherapy needs to respect and embrace the ways in which autistic people experience the world, and their different ways of being. On the other hand, psychotherapy is in principle posed to maintain an element of critical disbelief towards what an individual professes to know about themselves. Indeed, the job of therapy is to work against the ‘default mode’, the cognitive and emotional automations of clients, when these automations fail them. Helping clients thus necessitates taking them seriously, not literally.

This impasse, we contend, may be solved by utilizing phenomenology, the philosophical method of inquiring about one’s experience ‘from within’. For medicine in particular, phenomenological approaches emphasize how conditions of interest are lived as unitary experiences, not as disparate biological bodily symptoms. Correspondingly, the focus of phenomenology-based mental health approaches is to make this experience better: to minimize suffering and maximize enjoyment for the involved individual.

Our proposal is not to straightforwardly ask clients what works for them and abide by that. We encourage therapists to maintain the critical attitude that is sine qua non for psychotherapy. What we promote is that the process is occasionally subjected to a phenomenological check: a review of how treatment has impacted the subjective well-being of the client. Therapists should not shy away from trying something new because it does not come easy to the client but, all the same, they should drop the plan if, given enough time, no substantial improvement is noted from a first-person point of view.

On a practical level, we are very sympathetic to the further dissemination of the practice of autistic therapists, who are more naturally posed to know what it is like to be autistic. Correspondingly, we urge non-autistic mental health practitioners to familiarize themselves with phenomenological literature on autism, and researchers to further develop such literature, following the young but strong movement to look at autism ‘from within’.

Is OCD Epistemically Irrational?

Today’s post is by Pablo Hubacher Haerle on his recent paper “Is OCD Epistemically Irrational?” (Philosophy, Psychiatry and Psychology 2023). Pablo Hubacher Haerle is a PhD student at the University of Cambridge. His thesis is on the epistemology and metaphysics of the mind. He is particularly interested in desire, inquiry and the philosophy of psychiatry.

Pablo Hubacher Haerle

On the mainstream picture of obsessive-compulsive disorder (OCD), people experiencing OCD have intrusive thoughts which lead them to form epistemically irrational beliefs. Consider this classic example: 

Amelia is driving in their car. Suddenly, she hears a weird noise which she can’t identify. She forms the belief that she’s run someone over and spends hours looking for the supposed victim.

But it is true that Amelia must have a belief that she’s run someone over? Following recent advances in the literature (Kampa 2020; Taylor 2021), I consider it much more plausible to construe Amelia’s recurrent thoughts as what if questions. This matters for the assessment of rationality, since the rationality conditions for questions are different from those for beliefs. Imagine that you discover an unknown spoor while hiking in the wild. Here, it seems rationally permitted to ask the question whether this means that a bear is near, even though it would be unreasonable to believe that a bear is, in fact, near. Moreover, given how high the stakes are, it might even be mandated to ask that question. 

This doesn’t mean that questions can never be irrational, though. As Jane Friedman (2019) convincingly argues, sometimes reality is so obvious it would be ridiculous to question it. If you’re directly looking at me, it doesn’t make sense for you to ask where I am. But even if you were to think that people like Amelia are irrational because they’re inquiring into questions whose answers are just completely obvious, there are other instances of OCD where the grounds for a charge of epistemic irrationality are much weaker. Consider this case, adapted from a clinical case study (Bhatia and Kaur 2015; Williams and Wetterneck 2019):

For four years, Joseph has had uncontrolled repetitive thoughts about being gay. He is constantly distressed about this. He constantly has doubts about his sexual orientation.

Joseph suffers from the condition of sexual obsessive-compulsive disorder where the object of endless inquiry is not something in the external world, but instead the patient’s own desires. This complicates the assessment of rationality since now we’re not guaranteed an objective viewpoint on how much evidence for this hypothesis Joseph actually has. He might have repressed desires. Moreover it’s unclear we can trust his own testimony because he might be affected by motivated reasoning as a result of homosexuality still being heavily sanctioned in our societies. Thus, it’s not true that Joseph’s inquiry is irrational in virtue of questioning the completely obvious.  

I conclude that so far we don’t know what’s epistemically irrational about this specific kind of OCD. It might be that OCD isn’t irrational after all, or that its irrationality is merely practical, or that there isn’t one form of irrationality common to all cases of OCD. Personally, I believe that what makes OCD epistemically irrational is the fact that it induces unsuccessful inquiries. But whatever conclusion will be reached in this debate, it’s clear that—in line with research by Lisa Bortolotti (2020) and Sahanika Ratnayake (2021)—also in the case of OCD we cannot distinguish between the pathological and the non-pathological by appeal to epistemic irrationality alone.

Introspection in the Disordered Mind and the Superintrospectionitis Thesis

This blog post is by Alexandre Billon who presents his argument in a paper recently published in the Journal of Consciousness Studies. This paper is a commentary on Kammerer and Frankish's article on what forms introspection could take.

Alexandre Billon

A couple of authors have suggested that schizophrenia and depersonalization disorder (DD) involve an enhancement of introspective abilities regarding certain important features of our experiences --- call that the Superintrospectionitis Thesis.

The Superintrospectionitis Thesis and Schizophrenia

In the phenomenological tradition, Blankenburg argued that reports of some people with schizophrenia ‘reveal, in a kind of immediacy the conditions of possibility of our existence that otherwise remain concealed’ (Blankenburg, 2001, p. 308). Likewise, Kimura (2001, p. 335) suggested that schizophrenia might render manifest, through introspection, the ‘innate structure of all human beings that happens to be hidden in healthy people owing to some mechanism or other’. More recently Stephenson and Parnas (2018) have compared schizophrenia to an ‘amplified mirror image’ that reveals a ‘differentiation or potential alterity implicit in the dynamic nature of subjectivity’.

The Superintrospectionitis Thesis and Depersonalization Disorder

The term ‘depersonalization’ comes from the works of the Swiss diarist Amiel who arguably suffered from it but was quite ambivalent with regard to it. He sometimes described it as an awful psychological disorder, sometimes as a metaphysical blessing and a confirmation of Schopenhauer’s Buddhist views on the unreality of self (Amiel, 1894). This ambivalence about DD is still common. 

Even though DD is usually dysphoric and the strange experiences of people with DD are usually considered misleading, the popular writer Suzanne Segal, aided by her Buddhist teachers, has argued that her DD was the first step of a spiritually enlightening journey (Segal, 1996). She has been followed by some philosophers who saw in DD a confirmation of Buddhist views on the unreality of the self (see  manuscript by Chadha, "Depersonalization and the sense of self") and has led many patients to question the deep meaning of DD (as witnessed by frequent discussions of DD forums).

I consider and reject various arguments for the Superintrospectionitis Thesis (coming from the phenomenological and Buddhist traditions and from evolutionary psychiatry) and I provide a simple, tentative argument against it, the “fine-tuning argument”.

The Fine-Tuning Argument

Suppose you open a radio receiver, choose one wire randomly, and disconnect it, or connect it to a different slot. Suppose that, as a result, you cannot listen to CDs on your stereo anymore. You might still be able to listen to your favorite radio stations. Maybe not. But the chances that it might now better receive the range of radio waves it used to receive, or that it might receive a new range of radio waves, seem extremely meager. The reason why is that a stereo is a fine-tuned system, that is, a system optimized to fulfill a certain set of functions, and whose functioning is extremely sensitive to a set of parameters. 

Accordingly, if you modify these parameters, you are likely to end up with something that cannot properly fulfil some of its functions, and extremely unlikely to obtain something that fulfils some of its functions better. Now, our minds are likewise fine-tuned: they are optimized to fulfil a certain set of functions, including introspection. On the most plausible accounts, schizophrenia, and DD are mental disorders, a mental disorder involves a (harmful) dysfunction of the mind (Wakefield, 1992), and it is extremely unlikely that a dysfunction of a fine-tuned system might make it better at fulfilling some of its (other) functions such as introspection.

The Fine-Tuning Argument does not forbid that some people with mental disorders might become better at introspection after some time, by a form of overcompensation or hyperspecialization (compare with auditory overcompensation to early blindness). Unfortunately, advocates of the Superintrospectionitis Thesis all claim that the earliest symptoms of schizophrenia (in fact the prodromes) and depersonalization disorder reveal a form of introspective enhancement. So overcompensation and hyperspecialization are excluded here.

(For interest, Kammerer and Frankish respond to this commentary here). 

Silence

This post is by Dan Degerman, Leverhulme Early Career Research Fellow at the University of Bristol, soon to join the new project EPIC (Epistemic Injustice in Healthcare), funded by a Wellcome Discovery Award. (A version of this post appeared on the EPIC blog on 15th September 2023.)

Some members of team EPIC: Matthew Broome, Ian Kidd,
Dan Degerman, Havi Carel, Kathleen Murphy-Hollies, and Fred Cooper.

Silence is an important phenomenon in mental health. But while philosophers have had much to say about the social silencing of people with psychiatric diagnoses, other ways in which silence can feature in psychopathology have been underexplored. In a recent workshop at the University of Bristol, generously funded by the Leverhulme Trust, we sought to begin to address this neglect by exploring the different faces of silence in psychopathology.

Ian Kidd opened the workshop with a talk that explored painful silences common in bereavement grief. In particular, he focused on four silences, each characterised by a loss of communicative possibilities that follows the death of a loved one. This included, for example, silence as the loss of the distinctive communicative style of the deceased and silence as the permanent absence of narrative closure. For the person subject to these silences, they are painful for three reasons, Ian explained. Firstly, these silences cannot be filled. Secondly, they involve the awareness that the ways of being in the world the relationship with the deceased made possible are now impossible. Thirdly, they involve the awareness that one can no longer be the same person that one was with the deceased.

Ian Kidd

The second speaker, Richard Stupart, drew on accounts of investigative journalists working in South Sudan to shed light on some of the mental dangers of being silent. He argued that journalists are at a heightened risk of moral injury, referring to the negative psychological impact a person experiences when they are unable to respond to a situation in what they consider a morally appropriate way. Journalists in conflict and crisis situations are particularly vulnerable to such injury because they often find themselves subject to structural pressures that may prevent them from communicating their knowledge about morally charged stories.

Richard Stupart

Inner speech in mental disorders was the subject of the next talk by Sam Wilkinson. He defended what he called a strong dialogical account of inner speech, which entails that all inner speech is directed at a recipient, namely, ourselves. This account also suggests, among other things, that inner speech plays a central role in shaping our identity. Sam then outlined some ways this account can help clarify the implications of inner speech and its absence in different mental disorders. For example, the strong dialogical account indicates that negative inner speech in anxiety and depression is not just an epiphenomenon of pre-existing a person’s feelings but that it can create a downward spiral of those feelings.

 

Sam Wilkinson

The fourth talk by Anna Bortolan examined experiences of silence in social anxiety. Drawing on some distinctions proposed in a recent paper on silence in mood disorders, Anna showed that these capture experiences described by people with social anxiety as well. She then went beyond that account to argue that a further two experiences of silence can be discerned in accounts of social anxiety. The first is characterised by a perceived inability to fill certain silences when one wants to do so, and the second is accompanied by a diminished sense of agency over how silences are filled.

Anna Bortolan

Finally, in my talk, I argued for the importance of attending to first-person experiences of silence in psychopathology through a case study drawn from accounts of depression. Using a phenomenological framework inspired by the work of Merleau-Ponty, I described an experience common in first-person accounts of depression that I termed empty silence. This is an unpleasant experience that involves a solicitation to speak and a breakdown in a person’s habitual relationship with words, which confronts them with their own outward and inner silence. I proceeded to argue that if lived repeatedly, it may give rise to bodily doubt in one’s ability to speak.

Dan Degerman

If you are interested in learning more about the talks, presentation materials from most of them can be found here. The talks were followed by wonderful discussions with the interdisciplinary audience that was in attendance in the room and online, and I want to extend heartfelt thanks to all those who participated.

The workshop was the capstone event for my Leverhulme Early Career Fellowship. However, it also served as an informal launch event for the EPIC project, with many of its team members in attendance, including Ian Kidd, Havi Carel, Matthew Broome, Fred Cooper, Kathleen Murphy-Hollies, and myself. The conversations and explorations that began during this workshop on silence and psychopathology will continue as part of the EPIC project, and if you are interested in contributing or participating in some way, please do get in touch.