I was recently invited to provide a guest blog post to the Cortical Chauvinism blog where I outlined some of my concerns with Silberman’s Neurotribes. It gives brief overview of some of the concerns which I have written about in various publications. Here is the link.
Back in April I presented alongside Rachel Cooper at an event set up by Accrington and Rossendale College. I wrote this blog post for the Lancaster University Bioethics and Philosophy of Medicine Blog but I thought I would reproduce it here since I mainly spoke about the History of Autism. Details on Rachel’s talk can be found on the Blog post.
My talk was entitled Lessons for today from the history of autism. The first half of my presentation was largely a re-cap of my previous criticism of Neurotribes (https://www.sciencedirect.com/science/article/pii/S1369848616300954). In this book Silberman (2015) argues Leo Kanner’s original description of autism (1943) was of a disorder that was “vanishingly rare” and “monolithic by definition”. Silberman argues that Kanner’s ‘autism’ was quite unlike the condition described as autism today. He claims that modern notions of autism have a significantly better scientific foundation and are much more suitable for neurodiversity than Kanner’s approach was.
However, in this paper I argued that when properly understood Kanner’s autism is much more like the autism that is described today than Silberman acknowledges. I argue that it is crucial to appreciate that Kanner considered autism to be a subtype of childhood schizophrenia (Kanner 1969). I argue Kanner thought it was only vanishingly rare in the sense of it being a rare subtype of the fairly common childhood schizophrenia. I accept that Kanner’s autism did have quite restrictive symptoms (even if it was not monolithic) but I situated it as being a subtype of a much less monolithic childhood schizophrenia which shared many symptoms of Kanner’s autism but did not require the stringent diagnostic criteria. Silberman claims that adherence to Kanner’s views prevented the full autistic spectrum being recognised for many decades but, if you consider Kanner’s views on childhood schizophrenia, it looks like Kanner endorses a position quite like a spectrum.
In the second half of my presentation I discuss some of my more recent research. I outlined Lauretta Bender’s (1956) approach to childhood schizophrenia and considered how elements of her approach fit modern psychiatric evidence surprisingly well. Additionally, they could be used to formulate alternative approaches to neurodiversity, one based around meaningful subtypes with nuanced inter-relationships between them, rather than an account of neurodiversity based around the DSM-5 spectrum which lacks subtypes.
As far as I was aware, none of the audience were professional historians or philosophers. I found it positive to deliver my work to a wider audience, getting the findings of my research out to a wider audience. Some of that audience were mental health professionals or training to become mental health professionals, thus some are or would be interacting with autistic people regularly in their line of work. As a historian and philosopher my work often can be a bit removed from actual practise, thus it was good to be speaking to and opening dialogue with individuals who have much practical hands on experience of working with autistic individuals. The audience were engaged and asked interesting questions. These included questions about alternative ways of thinking about diagnosis, what the value of diagnosis was, how to keep in focus the aspects of the individual not covered by the diagnosis and even if diagnoses were needed at all. I think these are all important questions and it was good to see questions about them. Overall, I feel that academics often do not engage sufficiently with the world outside academia. It was very encouraging to attend a talk which was so well attended by an audience who asked engaging questions so I feel the whole process was very much a worthwhile experience.
Petteri Pietikainen’s 2015 Madness: A History intends to provide a general history of psychiatry, the author intending it the first general history since Shorter’s 1997 A History of Psychiatry (presumably Pietikainen started this book before Scull’s recent book came out). The scholarly quality appears to be first rate, a well researched analysis with lots of well thought out arguments. It also covered some ground which I’d not seen discussed elsewhere. On this basis the book is recommended. I do wonder if some of the material is too specific for a general history, such as the chapter on cold war psychiatry which included a section on various attempts at mind control, or the 1960s research into sensory deprivation. To my mind, these are not so crucial as an in depth discussion of the origin and evolution of the DSM, which is present just not as long as I’d like (though that is my specific interest so I might be biased). Basically, providing one reads the book without the assumption that the book will provide THE full history of psychiatry then it is recommended.
The part I found most interesting was Pietikainen’s remarks at the end of the book. He is broadly critical of two relatively recent trends. Firstly, modern focus upon what he calls the “worried well”, which are roughly people with relatively minor psychological issues. This he considers problematic because it can make people with relatively minor issues believe they have serious problems, “influence the person’s self-understanding and potentially cultivate a culture of vulnerability, no matter if it is done with a benevolent purpose”. Meanwhile, this distracts from helping people with more serious issues. Secondly, and relatedly, insufficient care for the more seriously mentally ill, especially after the 1980s “dismantle [of] the Keynesian welfare state”. Since then, “a solid infrastructure of mental health services is still missing in most if not all western countries. As a consequence of deinstitutionalization, homelessness skyrocketed, for example in the UK and the United States, and a growing number of mental patients ended up on the streets, in jails or in shelters for the homeless”. In contrast to some recent histories of psychiatry (especially recent histories of autism), this history suggests that in some important reguards things have actually got worse for the severely mentally ill. Recognising the good intentions behind community care, Pietkainen suggests this ultimately can result in simply not really doing anything to help the mentally ill. “If the mentally ill do not have a safe place to go and receive treatment – other than pills – then how does ‘community care’ differ from systematic negligence?… We have gone around full circle and are back in a world that has uncanny resemblances with the ‘pre-confinement’ era, with the exception of psychiatric pills, patient organizations and the individual ethos of self-management”.
Being a 1930s onward historian and primarily dealing with psychiatric classifications rather than psychiatric care, I’m not really in a position to judge the accuracy of these claims. I do, however, find them fascinating: the idea that without realising it through dressing up our modern situation up as community care and user led care we have returned to situation which most people would be deeply upset about if we realised it had happened. It makes one think about the power of concepts to shape perception, that by portraying (presumably in good faith) many modern innovations in a positive light modern psychiatry has only concealed how badly they are not working. Ultimately, I cannot judge if Pietkainen is exaggerating these claims, so I treat them with caution, but I cannot rule out the possibility they are partially or even wholly true. If so, his message is important and deserves a wider audience.
I have just finished a major update to Kanner’s bibliography:
Kanner’s In Defense of Mothers arrived last week, having been ordered from America. It was published in 1941, two years before he developed his notion of autism. This books is very different in focus to most his writings, unusually being primarily about children who did not see psychiatrists.
The message is primarily ‘let children be children’, and to a lesser degree ‘let mothers be mothers’. He seemingly has a notion of natural mothering and believes this is distorted through bad advice given by various sources of supposed experts on mothering. He tells mothers not to insist on rigid diets, not to overburden the children with work, not to interfere dramatically in the child’s social life (i.e not decide who their friends can be), trying to counter various cultural sources who insist the mother must perfectly raise children lest the child ends up neurotic and delinquent. He thinks society should just let mothers be mothers, which would mean mothers would let children be children, a good route to healthy children in Kanner’s view.
There was very little about psychoanalysis in the book. The specific claim that poor mothering causes mental illness (such as childhood schizophrenia) was not really discussed (there were some ambiguous passages related to this but much more moderate than what came later). Whilst such claims really took off around 1950, it seems they were of little significance in the early 1940s.
The guiding principle throughout the book was ‘put the child in context’. If the child does something bizarre then there probably is good reason for this, talk to the child, try to understand what is happening with their life, but do not take this as a sign of some ominous symptom that must be immediately countered. This looks like Kanner taking a Meyerian approach, emphasising the individual as a whole who must be understood contextually, rather than more common approaches of just interpreting everything under one pet theory, something some child psychaitrists did and Kanner hated.
It was interesting to see Kanner would often describe the family in political terms, outlining a democracy as an ideal family where the child was an active member who was listened to. This contrasted with totalitarian families where the exact path the child must take was laid out in advance by the parents. Written in 1941, using such political terminology was understandable.
Overall, I’d put In Defense of Mothers as Kanner’s least valuable book to read, measured by all those published since he became a child psychiatrist. It does not particularly illuminate Kanner’s views, at least not more so than his 1935 text book, which goes into much more detail. It does give some nice social history though, giving a good feel for early 1940s American approaches to childhood.
This time last week saw the end of the BSHS annual conference. My talk seemed to be received well.
I’d never been to a history conference before and found myself pleasantly surprised. Everyone was very friendly and there was very little confrontational arguments. Typical questions were along the lines of asking speakers to expand upon their argument, what else was going on during these particular events, what theories were dominate, how did this relate to what came before and afterwards, how did this relate to activity in a wider setting (other counties, other sciences). Questions allowed the speaker another opportunity to discuss their research. This felt quite different to philosophy conferences (which I am more used to) where quite a few questions, though by no means a majority, focus upon criticizing the speaker’s argument: what about this counter example, surely you are making this particular assumption, maybe you should consider whoever’s view points. The history approach certainly makes for a more relaxing conference but which one is best? Generally, the history questions gave opportunities to present more empirical evidence rather than specifically defend a particular argument. Philosophy is typically more about defending the argument. To varying degrees (and with many exceptions) both history and philosophy need an empirical basis and a strong argument. The historian seems to build up from lots of empirical evidence to an argument whereas philosophy focuses more on the argument but then often need make their argument compatible with empirical evidence, i.e. fit available evidence as so avoid counter arguments. Personally, I prefer philosophy when it starts with a lot of empirical evidence and tries to analyse that evidence, systematise it and see how it relates to wider bodies of knowledge. I do not know how far it could be taken but I think philosophy could benefit from some approaches adopted by historians.
The other difference is how specific many history papers were, totally unrelated to my field, whereas most philosophy of science is relevant to most other philosophy of science. With exceptions, I think a philosopher of physics could still benefit from seeing, say, a philosopher of biology speak. Both cases may use notions in similar or different ways, i.e. cause, explain, predict, inductive, law, model, etc. You can learn from both the similarities and the differences. The benefits of attending many presentations at history conferences are less obvious but still there. History of 1800s paleontology is no use to the history of autism but you see a historian try to create a historical narrative or create explanations from a particular type of evidence, often using very different type of evidence than I’m used to. For instance, that presentation on paleontology had to appeal to a very limited number of paintings to understand 1800s views of woolly mammoths whereas I primarily deal with journal articles. Someone else deals with diaries, another with hospital records, another with medical equipment. Observing how a historian employs a particular type of evidence, with associated limitations that evidence brings, makes one reflect upon how I go about using evidence, how reliable is it, how representative is it, what is it missing, etc. A useful experience, but, again, useful in a different way to the benefits of seeing philosophers of science dealing with other sciences speak.