Abstract
In this article, I argue that the history and philosophy of autism need to account for two kinds of autism. Contemporary autism research and practice is structured, directed and connected by an ‘ontological understanding of disease’. This implies that autism is understood as a disease like any other medical disease, existing independently of its particular manifestations in individual patients. In contrast, autism in the 1950s and 1960s was structured by a psychoanalytical framework and an ‘individual understanding of disease’. This implied that autism was not a distinct disease but an idiosyncratic and meaningful response of the child to a disturbed development of the ego. These two kinds of autism are embedded in and reveal two very different ‘styles of psychiatric thought’.
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Notes
From a metaphysical point of view, what is considered to be a ‘disease’ is far from settled and tracks longstanding and contentious debates in the philosophy of medicine regarding notions of health, disease, normality and dysfunction (see e.g. Ereshefsky (2009) for a flavor of these debates). I will not rerun these longstanding discussions. When I discuss the ‘ontological understanding of disease,’ I am not concerned with the abstract philosophical question regarding a ‘true’ nature of disease, independent from how researchers or clinicians investigate and have come to think about disease.
This distinction should not be confused with the much used distinction between disease and illness (see Boorse 1975) that, within the ontological-individual typology, would be part of the ontological understanding of disease.
Temkin, for instance, points out that it is no coincidence that ‘Sydenham, the ontologist, lived at the time of the great plague of London, and the plague, I understand, has little concern with individual variations’ (Temkin 1977, p. 455).
Somewhat confusingly, Temkin (1977, p. 442) also used the term ‘physiological’ next to ‘individual’ to contrast with the ontological understanding of disease. In this context, I suggest that ‘individual’ is the more appropriate term to group understandings of disease that focus on the human person as a whole.
Even before that, there are signs of generalization and an ontological understanding of disease when Rhazes of Persia differentiated between smallpox and measles in the ninth or tenth century.
In contrast with Rosenberg (2003), Osbourne (1998) does not regard modern concepts of disease as ‘ontological’. Instead, he argues that if ‘medicine is to be characterized as reductive this should not be in terms of its ontological fixation but for something quite different … namely a certain … predilection for monist explanations’(1998, p. 267). The distinctive character of modern medicine, he continues, ‘is not that it is ontological but, on the contrary, that it has rid itself of any constitutive ontology’ (ibid.). For Osbourne, an ontological understanding of disease seems to require that the disease is thought to be identical with a foreign thing, ‘a morbus that attacks the body’ (ibid.). To me, this interpretation of the ontological conception appears much too stringent.
Autism expert Simon Baron-Cohen (2000) similarly argues that autism is not necessarily a disorder. I do not take a position in this discussion as I merely try to describe the different positions and ideas about disease and abnormality in relation to autism.
According to Temkin (1977, p. 445), Hippocrates was ‘outstanding for having seen disease as a process in time, not a mere stationary picture’ and for taking into account ‘the peculiar nature of each individual’.
Eugen Bleuler, who had coined the term autism in 1911, attributed its etymological roots to Freud, and ultimately to the British sexologist Havelock Ellis, through the term ‘autoerotism’. Freud had used this term in 1899 in a letter to Wilhelm Fliess: ‘The lowest sexual stratum is auto-erotism, which does without any psychosexual aim and demands only local feelings of satisfaction. It is succeeded by allo-erotism (homo- and hetero-erotism) but it certainly also continues to exist as a separate current’ (Freud 1950, p. 280).
For more on how these practices relate to the regulatory and bureaucratic practices in more exoteric communities of psychiatric health care, see Verhoeff (2014).
The contemporary dominant ‘style of psychiatric thought’ has not remained unchallenged and ‘critical psychiatry,’ ‘postpsychiatry,’ ‘the recovery movement’ and ‘values based practice’ are examples of oppositional voices at the margins of academic and clinical psychiatry (see e.g. Bracken et al. 2012). However, what is generally missed in these critical accounts is how different scientific, clinical, philosophical and institutional aspects hang together in a coherent and constraining way.
In his essay The Tyranny of Diagnosis (2002) Rosenberg points to the fact that, for about the past two centuries, diagnosis is central to the definition and management of what we call disease. He argues that diagnosis constitutes ‘an indispensable point of articulation between the general and the particular, between agreed-upon knowledge and its application. It is a ritual that has always linked doctor and patient, the emotional and the cognitive, and, in doing so, has legitimated physicians’ and the medical system’s authority while facilitating particular clinical decisions and providing culturally agreed-upon meanings for individual experience’ (2002, p. 240).
This idea resembles Canguilhem’s other counter-intuitive idea that ‘the abnormal, while logically second, is existentially first’ (Canguilhem 1966/1989, p. 243).
Nobody understood this better than the pharmaceutical industry when it launched antidepressant and antipsychotic medication that acted on separate monoaminergic pathways that were later (incorrectly) claimed to be the specific dysfunctional neurotransmitter pathways in depressive and psychotic disorders (see Rose and Abi-Rached 2013, p. 36–37).
A therapy that was thought to produce psychological change through the creation of a therapeutic environment or milieu that encompassed all aspects of life. Bruno Bettelheim’s Orthogenic School was such an environment.
For more on how RdoC will try to base classification on pathophysiology, see http://www.nimh.nih.gov/research-priorities/rdoc/index.shtml. Accessed 24 March 2014.
Molecular Autism has the highest impact factor in 2014 of all autism journals.
See Evans (2013) for a closer look at this development of autism research in the 1960s.
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Verhoeff, B. Two kinds of autism: a comparison of distinct understandings of psychiatric disease. Med Health Care and Philos 19, 111–123 (2016). https://doi.org/10.1007/s11019-015-9655-4
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DOI: https://doi.org/10.1007/s11019-015-9655-4