Asking the Right Questions on Autism and Depression

Earlier this year, an issue of the journal Philosophy, Psychiatry, & Psychology (PPP) featured a number of articles and commentaries separately focused on issues concerning autism and depression. Two of the authors from the issue, Aaron J. Hauptman (Chief Resident Physician, Pediatric Psychiatry Consultation/Liaison Service, New York University; Clinical Instructor, NYU School of Medicine, Department of Child and Adolescent Psychiatry) and Nancy Nyquist Potter (Professor, Department of Philosophy; Associate with the Department of Psychiatry and Behavioral Sciences; Core Faculty, Interdisciplinary Masters in Bioethics and Medical Humanities at the University of Louisville) joined us for a Q&A to talk about these important issues and how the journal issue contributes to the discussion.

How important do you think it is for an issue to focus on issues like autism and depression?

NNP:  PPP is at the vanguard in addressing under-analyzed and difficult issues in psychiatry, and both contributors and readers are fortunate that such clinical and philosophical work is available to us.  Significant numbers of people suffer from various forms of depression and autism in North America and Europe. Yet neither is well-understood phenomenologically or able to provide adequate treatment for many. Clear philosophical analysis, empirical research, and collaborative discussions go a long way toward identifying goals in care and treatment for these disorders. What are realistic goals for people living with autism or with chronic or debilitating depression? Are we at risk of settling for less when looking at various patients’ struggles from a different angle might suggest we can and should ask and offer more for their lives? Cutting-edge treatments can be explored and evaluated in light not only of research results but also for the philosophical underpinnings of various claims, assumptions, and argumentation—especially when we are participants in a discussion together. This is where PPP is so essential: it opens up hard thinking and thoughtful examination of problems in psychiatry that are sometimes overlooked.  

AJH:  I think it is wonderful when a volume of a cross-disciplinary journal like PPP can focus on a topic that is both medically very important and also fraught with complicated philosophical issues.  Before even considering the issue of clinical management, there are a lot of problems with things like how to even define these conditions, nosology and categorization, the ethics of how or whether to treat, etc.  This is where the dialogue between clinicians and philosophers can be most rich, which is why I am so enthusiastic about such endeavors.  The medical advances drive the conceptual terrain and the philosophical exploration makes more rich and, ultimately, helps refine, the medical understanding. 

I feel strongly that not enough attention is paid from the clinical side to the careful reasoning that is being done by philosophers of psychiatry (and philosophers in other disciplines) that can help us understand the individuals with whom we are working, the conditions that impact their lives, and issues that are associated with treatment.   

How helpful is the journal's format with the ability to respond or use narrative to examine the issues?

NNP: Narrative medicine, and narrative psychiatry, is a burgeoning field. Case studies are one way to begin to present a narrative. But most often, case studies are written by psychiatrists and from their perspective. Narratives expand on this idea, and it is especially helpful when first-person accounts of mental distress are offered. Readers are better able to grasp the particular sorts of problems, strengths, and triumphs from someone who tells their own story and then clinical insights and theoretical frameworks can be interwoven. As we know from our everyday lives, we frequently see things from a different perspective than others do—and that can make all the difference in the world to understanding and communicating. The more perspectives we can gather—and in particular, the more first-person accounts of experiences of mental disorders circulate in academic and clinical sources, the more accurate our classification will be, the more empathetic clinicians can be, and the more likely that diagnosis and treatment will be good. First-person and narrative patients’ accounts provide a richness that is missing when only clinicians and philosophers do the theorizing.

AJH: I think that the use of narrative and clinical cases in the journal offers a number of opportunities to bridge the divide between those working on the clinical and conceptual sides.  It also allows for the integration of patient/client/consumer experience as well, which is often excluded from this dialogue. 

The format utilized here provides the opportunity for discussion and back-and-forth even within a single volume, and the integration of a number of different voices, which is particularly useful in such multi-disciplinary topics.  Also, I think that use of specific cases both lets clinicians engage in philosophical dialogue (with which we are often less comfortable) while simultaneously it provides philosophical colleagues with real-life scenarios that can help ground their conceptual work. 

Prof. Potter, what did you learn from your participation in the commentary section?

NNP: One of the main things I grappled with when I read and thought about the question of autism and flourishing is how to think well about the delicate balance between aiming high for the goal of flourishing, on the one hand, and wanting to put the brakes on what I consider to be an unattainable ideal not only for people with autism but for the rest of us. The question for me is, How can we know what is possible for people living with autism to experience? What epistemological resources and skills need to be in place in order for us to begin to get clear on this issue? What ethical and social theory of flourishing should we draw upon or develop? What do different people living with autism say themselves? I learned that we need to talk more together, and listen well to one another, in order to go forward both with adequate treatment and with ethical goals.

Dr. Hauptman, how hard is it to balance privacy issues with a desire to learn from individual clinical experiences?

AJH: The balance between confidentiality and education comes up often throughout medical pedagogy and writing.  We can talk in general cases, but that tends to be far less rich than in the discussion of a real person's actual experience.  The history of medicine, really, is built on clinical cases, up until the more recent advent of large-scale studies.  In fact, most physicians probably could rattle off some of the names of famous patients whose stories form a foundation in medical literature, both to elucidate concepts and to add something more human and personal to what can be otherwise rote memorization. 

Clinicians are careful, by the nature of their work, to de-identify details, or combine multiple cases when appropriate, or obtain patient permission to discuss specific details, all according to the particulars.  All that being said, one's patient is still one's patient and the goals of education, while very important, come a distant second to that important and unique relationship.  

Where do you hope the discussion on these issues goes from here?

NNP: I would hope that this discussion is extended out to the community, reaching clinicians, nurses, patients, families, and other interested and concerned parties. There are at least three primary questions I would like a wide community of experience to converse on: first, questions about what the aims for living should be for people living with depression and autism; second, what arguments, evidence, and phenomenological experience back up these ideas; and third, what counts as good treatment care for particular patients who carry these diagnoses. The last issue raises the point about useful research topics, which loops back to the need for open dialogue in order to know more about what best serves patients’ needs.

AJH: In medicine, there are a lot of factors that govern why one does what one does. These include best practice recommendations, clinical trials, medical-legal considerations, etc.  Often, though, we don't get the opportunity to sit back and deeply consider the underpinnings of our intuitions, decisions and actions.  This might include things like why we consider a particular thing a disorder, what it even means to be an illness, what are the ethics of treatment in even clinically straightforward cases.  There is a growing literature that uses philosophical techniques to approach areas in mental health, and I hope that our own multi-disciplinary dialogue supports this and helps not so much move a conversation forward, but model a way to have this kind of conversation and, hopefully, provide an example of how people from different disciplines can engage with some of these questions together towards the goals of better understanding and better futures for those whom we are trying to help.