With Therapy for Asperger's, a Conundrum
A common conversation that I have in my NYC therapy practice concerns Asperger’s. Many people wonder if they have Asperger’s or if their parent or spouse does. There are people whose life matches the diagnosis of Asperger's, more or less. Some find that discovery a relief and some find it an annoyance. Many find the diagnosis–whether a formal or informal diagnosis–simultaneously both.
It’s not that one response to an Asperger's diagnosis is accurate and the other isn’t. It’s not that, in one case, the individual finds those traits burdensome while, in another case, she or he finds them just fine or even, desirable. How do we account for that?
You Don’t Get To Diagnose Yourself
I mean, you could (and many do), but it doesn’t solve the riddle. Just inviting everyone to be in charge of their own diagnosis doesn’t mean we’re freed of the troubling paradox of diagnosis. These words have gravity beyond the power of one person to change–even, one person and his or her therapist. It doesn’t work like that.
Perhaps the dilemma seen with Asperger's is true of nearly any mental diagnosis. With a diagnosis of major depressive disorder, one person can feel like they’re finally being taken seriously while another is annoyed at the diagnosis, feeling it too narrowly defines a complex experience.
But, Asperger's Feels Different
Unlike “depressed” or “anxious,” Asperger's doesn’t exist as a part of our everyday conversation. There’s something mysterious about it–both because it’s relatively new and because its definition is in flux.
Also unlike depression, which most educated people understand as a real phenomenon that people struggle with (really all of us, at times, in different degrees), Asperger's is a disorder defined by a collection of attributes. Further, those attributes aren’t socially neutral. The syndrome, as described in diagnostic language, is characterized by difficulties in social interaction and “restricted and repetitive behaviors or interests.” It’s hard not to hear the word Asperger's, look up the definition and not think that the attributes are effectively those of a nerd.
In some ways, when I try to talk to patients about Asperger's, we find ourselves tongue-tied. One person with Asperger's compared to the next may seem, to an observer, to be quite different. And that’s because they very well might be. The term has come to be roughly synonymous with social awkwardness and having odd interests. I don’t say this to diminish the seriousness–there is often a very, very real struggle. But I don’t think even the best of diagnostic science has much of a solid sense of just what we mean by Asperger's.
Asperger's and the DSM-5
It is important to note that Asperger's was actually removed from the DSM in its most recent iteration–the DSM-5. It had previously existed as a separate diagnosis from Autism in the category Pervasive Developmental Disorders. Autism is constructed in the DSM as existing on a spectrum–more or less, from high to low functioning.
Asperger's has always been thought of as a sort of mild Autism, but that’s now been formalized in the DSM-5. The term Asperger's is now a diagnostic relic. Many people have been sad to see it go–largely, people who found the Asperger's label not just helpful in understanding themselves, but also as an identity to be proud of. The word is still used, but now, there’s what’s considered an Autism spectrum with degrees of severity. Also of note, both Asperger's and Autism are now considered syndromes rather than disorders–another adjustment to soften the pathology.
There is a pro-Asperger's and a pro-Autism movement. I’m agnostic on the question of whether that’s good or bad. For one, it’s not for me to say. People find meaning and often fraternity in these spaces. Many of these people have felt alienated and picked on so it feels meaningful for them to have those spaces.
Asperger's Is Only Part Of The Equation
My fear more than anything is that we get small in how we talk about these things. I’m more concerned with the pervasiveness of the term and its diagnosis both formally and informally.
There is a sort of category error in how we relate to the contents of the DSM. On one hand, we have depression, which is seen as an emotional experience that can come and go–or, at least, ebb and flow. In other instances, we have so-called personality disorders, which are generally understood, as their name suggests, as permanent parts of someone that can be managed, but will not go away.
Asperger's is in a similar category. It doesn’t come and go and not many people relate to it as something that can be cured. One category error is relating to these as though they’re the same rather than a mental state versus who a person is.
Another mistake is related to the understanding of these as discrete phenomena. We might commonly say that an individual suffers from depression and anxiety, but when we’ve identified someone as having Asperger's, we tend to see their depression only within the framework of Asperger's. Can someone with an Asperger's diagnosis seek treatment for depression or anxiety (or social anxiety) without the setup that they are “seeking treatment for Asperger's"?
If we extend this, we can look at the question of what it means to help someone with their dating life, get a better job or learn how to better deal with his or her sister. These are all things that people seek therapy to get help with. Having Asperger's or finding some connection with that word may be terribly relevant in working on all of these issues, but Asperger's also tends to dominate how the treatment is constructed.
Maybe helping someone with Asperger's with their depression needs to look a lot more like helping anyone with his or her depression. Of course, good treatment is particular to the person, but there are ways that Asperger's can be made to not dominate the conversation. When therapists say, “I work with people with Asperger's.” I find myself asking to myself, “You work with them at what? What are you helping them with? Who they are is only part of that equation.”
Are you Asperger's-ey?
What I’m helping people with Asperger's (or people who think they may have Asperger's, who have been told they do or feel they have some traits) with is exactly what I’m helping anybody with in my NYC therapy practice. I want them to not be in pain and I want them to grow their lives.
I approach people with Asperger's exactly as I would anyone else–with curiosity and compassion, with a “let’s get to work” attitude and with an offer that I’m willing to work to help them with anything they want. Of course, it’s helpful that I’ve done a good deal of work with folks who are of this ilk.
There may be valuable, rich conversations about diagnosis or a given individual may be tired of that. We give the label as much or as little value as we decide to give it in the service of our work. And sometimes it’s even helpful to put the diagnosis aside and define our own relation to the word.
For instance, we can say someone is “Asperger's-ey” or “Asperger's-ish.” We can explore what fits and what doesn’t about that construct. The idea that one label or one handful of words can define someone is absurd. But the idea that a label and a whole set of associations can be considered by those who are trying to make sense of who they are as people who don’t fit the standard mold? That seems filled with potential value.
