Friday, 23 December 2016

where did bleuler's autism go?

When Eugen Bleuler coined 'autism' for us he propounded it as the central explicatory feature of 'schizophrenia' (another of his coinages). (Thirty years later Kanner and Asperger famously took it up as the name for a developmental condition - but the difference between infantile and schizophrenic autism was that the former involved a failure to enter the affectively-constituted, meaning-stabilising, intersubjective world, the latter involved a dropping away from it into private fantasy and unaccountable trains of thought.) Bleuler's concept of autism was multi-faceted. The schizophrenic psychoses, he declared, are

characterised by a very peculiar alteration of the relation between the patient’s inner life and the external world. The inner life assumes pathological predominance (autism). The most severe schizophrenics, who have no more contact with the outside world, live in a world of their own. They have encased themselves with their desire and wishes (which they consider fulfilled) or occupy themselves with the trials and tribulations of their persecutory ideas; they have cut themselves off as much as possible from the any contact with the external world. … This detachment from reality, together with the relative and absolute predominance of the inner life, we term autism.

Bleuler explains that his term is nearly coterminous with Freud’s autoerotism but that he chose a new term because Freud’s greatly expanded sense of eros/libido can be misleading. He also explains that unlike what he saw as Janet’s quite general concept of ‘loss of the sense of reality’ (diminished ‘fonction du réel’) , he considers autism to characterise the patient’s reality relation only in the ambit of her complexes. Autism for Bleuler means a circumscribed withdrawal from reality - into what today we might call a ‘psychic retreat’ (Steiner) or ‘autistic enclave’ (Tustin) - which withdrawal provides the condition of possibility for the flourishing of delusional experience and thought.

A key aspect of Bleuler's autism is its psychodynamic intention. There are three central aspects of this. First, the autism Bleuler describes involves a world of private fantasy in which wishes and fears are considered realised. This indicates a form of mentality which Freud described as no longer subject to the so-called reality principle but instead governed by the so-called pleasure principle. Second, Bleuler's autism involved a motivated retreat to this world - i.e. away from an interpersonal world that was overwhelming, and towards a private substitutive domain. Third, central to Bleuler's autism, and a key reason why he was not happy to go along with Janet's conception of a generally diminished fonction du réel is that he saw autism as only affecting the patient in the ambit of her complexes. Someone may be perfectly in touch with reality when this reality is not challenging to her sense of self-worth, when it doesn't remind her of her failures or unmet desires or shame. But trigger such complexes in someone with a schizotaxic disposition and autism supervenes; it is not that the patient retreats to their own delusional and idiosyncratic solipsistic domain. 

This essentially dynamic conception of autism is lost in the contemporary formulations of Sass, Parnas, Stanghellini et al. Marvellous and hugely illuminating as their descriptions of autism are, they typically deny that psychodynamic matters enter into the heart of the autistic condition itself. At best they are conceived of as secondary withdrawal reactions to a primary disturbance in general pre-reflective attunement. But were autism really a deficit merely in vital contact with reality then Bleuler would never have coined the term - instead he'd have made do after all with what Janet's take on diminished reality contact (l'abaissement du niveau mental - due to loss of psychological tension and lost vital contact with reality. 

I just used the phrase 'vital contact with reality' which belongs to Eugene Minkowski. Today's phenomenologists view Minkowski's work on schizophrenia (in La Schizophrénie (1927) and other works) as the profoundest exploration of that topic yet. Sadly my French is terrible and his book hasn't been translated, but from what I've read of the other works it seems clear that the general assessment of Minkowski's phenomenology is right. Here we meet with no crass psychologising of schizophrenic psychopathology, but a deep exploration of the disturbances in intersubjectivity and temporality and spatiality which we meet with in the existential foundations - rather than the psychological upper storeys - of the schizophrenic mind. But what strikes me about such of Minkowski's work as I have read is its peculiarly delibidinised quality. Matters of sexuality are given a secondary place in the structure and function of the human psyche. They are not - by contrast, say, with the phenomenologist Maurice Merleau-Ponty (or others today, such as Jonathan Lear) - seen as ontologically central in the being of the human. Instead they are seen, as it were, as 'merely' psychological. The matter of our conflicted struggling with bodying-forth in our bio-motivational drives is relegated to a kind of disturbance of mental content rather than to a disturbance in the unfolding of mental form. I'm not going to try to make the case for all of that here, but instead turn to an example from an essay by Minkowski on the 'interrogative attitude'. The case he cites is that of Paul C, a socially withdrawn 17 year old schoolboy. Here I borrow the abstract provided by Louis Sass:
Paul C. had long been overly logical and precise in his style of thinking. An acute disturbance began with mental fatigue along with apparent obsessive symptoms (e.g., extreme monitoring of his own actions) to the point that simple, everyday actions became very time-consuming; he also developed a tendency to ask endless questions even about trivial phenomena. However, unlike those of the true obsessive, Paul's monitoring, doubting, and querying seemed to lack any emotional or personal element; he was not anxious but, rather, apathetic. Also, Paul lacked real curiosity: To him, everything had the same level of importance, and his attention was not directed by any precise or personal goal.
This paper argues that Paul's interrogative attitude was actually a form of autistic-schizophrenic thinking characterized by "pragmatic weakening" and a loss of vital contact with reality, which are consequences of a weakening of the "élan vital" with its "vital propulsion toward the future." Such patients retain their intellectual powers but do not use these powers in accord with the requirements of reality. The interrogative attitude can be seen as a compensation mechanism—a way to maintain some minimal contact with the world. The paper ends with psychotherapeutic recommendations.
The paper provides a brilliant description of Paul's diminished élan vital - a Bergsonian concept (although nb Bergson developed various of his concepts out of his reading of Pierre Janet's book on neurasthenia - Bergson's 'attention to life' being somewhat synonymous with Janet's 'reality function' - (cf Pete Gunter's interesting essay on Bergson and Jung)) - but provides scant information about his inner emotional life. Early on we are told that the beginning of this seventeen year old boy's condition 'goes back approximately nine months. Paul started complaining about a lack of energy and mental fatigue. Some time before this, he seems to have been preoccupied with questions of a sexual nature; he would question his father and ask him for explanations, revealing a complete ignorance of the subject.' This is the last we hear of any explicit mention of sexual preoccupations; later Minkowski opines that  The sexual curiosity that appears at the outset of the illness, which could be considered for that reason a point of departure, can only be a precursory sign of the interrogative attitude that takes a firm hold afterwards. In any case, it is this attitude that must be rectified before attending to anything else.’  But, well: why on earth can it only be considered that?! How odd that the central preoccupation of a (of any!) seventeen year old boy should just be lost from view in this way!

There are however some clues as to the possibly psychosexual significance of Paul C's symptomatology. Thus of two significant symptoms we find that one involves taking more than an hour to put the handkerchief under the bolster before going to sleep (don't ask me why these dudes were putting handkerchiefs under their bolsters in the first place). When asked for explanation Paul said that 'he wants to make sure that the handkerchief does not hang out anywhere beyond the bolster under which it is placed.' (Freud would have a field day!) Another symptom is spending hours in the bathroom. When asked for explanation all we get is the description of what Minkowski calls his 'morbid rationalism' - i.e. perseverative non-instinctual unstructured hyper-reflective devitalised thought and action. Why all this should happen particularly in the bathroom and bedroom, and what drives it all in the first place, is missing. When it comes to cure, Minkowski provides Paul with work on copying and translation. The occupational cure gets him somewhat engaged with reality again, but we can hardly imagine a less nocturnal (i.e. delibidinised) activity. We are left in the dark as to whether he has managed to integrate his instinctual life, we are left in the dark too as to why his soul is dirempting itself in the manner described. The meaning of Paul's initial attempts to put his struggles into words (his questions to his father about sex) are simply ignored. (Witness the fate of many a schizophrenic mind?)

Bovet & Parnas tell us that they think Bleuler's autism got lost because of his unhelpful psychodynamicism - and that if we just stuck to a Minkowski/Blankeburg line in our phenomenology we can develop a psychopathology that maps more neatly onto the biogenetic neurological drivers of the condition. I don't disagree with the significance of the neurological and the genetic to the development of schizophrenic pathology, but why our conception of the  biological should be thought to exclude the motivational and dynamic in this way is beyond me. Surely one can't get more neurobiological than instinctual matters such as the libidinal drive. Poor Paul C, it occurs to me, may well not seem to have managed its integration at all. (Let's face it, it's hard enough for the saner amongst us.) A properly psychoanalytic account is an account of the vicissitudes of the drives - that is, of such structures as are of their nature at once motivational and biological. For whatever largely constitutional, or perhaps sometimes also environmental-developmental, reasons, an inability to integrate the interests of the drive within the developing personality leads - so the theory goes - to massive defence formations, the creation of autistic retreats and delusional worlds, etc. ... 

Far from the psychodynamics being unhelpful, it seems to me to be key in understanding why it is that schizophrenia tends to develop in late adolescence - with the psycho-socio-sexual challenges of that time. But what it also does is allow us to understand a key further part of Bleuler's concept of autism - that it precisely doesn't stand either for some quite general abaissement du niveau mental or for a quite general loss of vitality, but instead refers to a state of mind only sometimes in the ascendant. Bleuler's idea is that it is just in the ambit of their complexes that the schizophrenia sufferer partakes of a way of being which pulls the inner and the outer worlds apart so destructively. A basal deficit theory, by contrast, not only provides less hope by way of treatment, but also less by way of understanding of the ebbs and flows of autism in the inner life of the patient. I would like to put it back to Bovet & Parnas: might it not in fact be the loss of the motivated-retreat-from-consensual-reality aspect of Bleuler's autism, and the development of quite general accounts of self-world undoing which treat not at all of matters of personal meaning and motivation, that set the concept of autism back so?