Mindblindness:Autism, Writing, and the Problem of Empathy
On the first day of class, Gregory stood out as different, even bizarre. While he contributed eagerly to class discussion, his comments were off topic and they often focused narrowly on his own concerns. Because this was a composition class, I noted immediately that his way of thinking about writing was rigid, mechanical, and occasionally extreme. In the first several weeks of class, for instance, Gregory probably asked a hundred questions, in and outside of class, about the mechanics of MLA citation. In addition, his speech was stilted and he did not look at anyone but me when he spoke. He also could not follow the class's jokes, although he seemed to have his own private sense of what was funny and would smile and rock in his chair when something amused him. There was something so unpredictable and unfamiliar in the ways he used and understood language that our communication always seemed off balance. While Gregory's oddball charm saved him from becoming a complete outcast, everyone in the group, myself included, had difficulty interacting with him.
The challenge that Gregory posed for me and for the other students in the class is that of understanding and empathizing with neurological difference. That is, while the other twelve students in the class and I all seemed to be distributed along the "normal" band of the neurological spectrum, Gregory presented as someone with Asperger's syndrome, a condition related to autism. People with autism are very rarely found in college classrooms, of course, owing to their typical difficulties with language and social interaction. Although people with Asperger's also have impaired social skills, fixed interests, and, at times, repetitive behaviors, they are more likely to attend college because they possess normal intelligence and language. Some, like Gregory, are characterized as "little professors" because they display both the extraordinary [End Page 1] intelligence and the social eccentricities commonly associated with the figure of "the absentminded professor." Although Gregory's behavior was unusual, his fundamental difficulty was communication. The other students struggled to make sense of his offbeat modes of self-expression, and he struggled even more profoundly to make sense of us and our expectations. Autism experts Uta Frith and Francesca Happé have examined the verbal communication of people with autism and Asperger's and found that, even for those whose language, vocabulary, and syntax are like those of neurotypical adults, communication and comprehension are still impaired, especially in situations that require them to take into account a listener's thoughts and feelings, such as when a listener needs to be supplied missing facts. They can also have difficulty with non-literal language and with the double-voiced and implicit humor of irony.1
Because Gregory's neurology limits his comprehension of irony, he could not appreciate that his presence forced me to confront the challenges of neurological difference in a course about medicine and culture that grew out of my research into the puzzle of autism. In fact, my work with Gregory compelled me to reframe my interest and to consider the challenges to affective and intellectual understanding posed by neurological difference in the particular context of the classroom. Thus, in what follows, I explore the promise and problems of empathy in situated institutional practices, such as teaching and medicine, as well as in writing. My central questions are these: In the interpersonal and institutional contexts of teaching and medicine, how does one make contact across a neurological divide? If language impedes comprehension as much as it enables it, then will such contact always be frustrated? In situations where verbal and affective communication are difficult, such as with neurological difference, is empathy possible?
A turn toward empathy is a turn into contested territory. In my chosen disciplines of literary studies and composition studies, as well as in clinical medicine, there is, understandably, considerable apprehension about venturing into realms of understanding that are governed by feeling rather than reason. Scholarship in the medical humanities, however, has focused more and more attention on the necessity of empathy in medical practice. Howard Spiro's anthology, Empathy and the Practice of Medicine: Beyond Pills and the Scalpel, maintains that the relationship between doctors and patients was profoundly transformed by the rise of scientific paradigms and bureaucratic medical practices that devalue emotional engagement with patients.2 Similarly, Jodi Halpern pushes against the repeated calls for physicians to treat their patients [End Page 2] with "detached concern" and argues instead for clinical empathy, which she defines as "a unique form of understanding patients that requires physicians to be emotionally engaged yet also promotes the objectivity that their roles demand."3 Halpern's definition complicates a common understanding of empathy that has its origins in the work of Theodor Lipps, a German psychologist who is credited with developing the concept of empathy in his 1903 text Einfülung. Lipps defines empathy as "the power of projecting one's personality into (and so fully comprehending) the object of contemplation."4 More familiarly, empathy is the belief that one could somehow step into another's shoes and see the world from that person's perspective. Maureen A. Milligan and Ellen Singer More also reject this simple version of empathy in their introduction to The Empathic Practitioner: Empathy, Gender and Medicine, in which they insist that clinical empathy should not be understood as a movement of the self into the other. Quoting Alexandra Kaplan, they assert instead that empathy is "the capacity to take in and appreciate the affective life of another while maintaining a sufficient sense of self to permit cognitive structuring of that experience."5 With this definition of empathy, Kaplan adds the significant step of distanced analysis, to which might be added yet another step—that of understanding and accepting the problems and limits of empathy.
Empathy can be disrupted by any difference, and the cognitive difference of autism obviously presents a profound obstacle to understanding. The difficulty those of us in the normal band of the neurological spectrum have empathizing with autistic minds is particularly ironic because autism itself is often characterized as an impairment of empathy or "theory of mind." "Theory of mind" in the literature on autism refers to "the ability of [the neurotypical] to attribute mental states (such as beliefs, desires, intentions, etc.) to themselves and other people, as a way of making sense of and predicting behaviour."6 The "theory of mind" hypothesis of autism maintains that people with autism do not develop such a capacity for intellectual or emotional empathy; they suffer instead from what is called "mindblindness."7 It may well be that many people with autism lack a "theory of mind." It is also the case, however, that imagining the minds of others is a complicated task for everyone. Theorizing or imagining other minds is indeed far easier for those of us who are neurotypical because most other minds are similar to our own. To extend this observation, we should also recognize that when most of us try to imagine an autistic mind, we tend to get into trouble. The challenge, then, for those of us researching and writing about autism is to figure out how to theorize [End Page 3] a mind that does not possess what seems a fundamental capacity for the social human, how to explain a mind with which we cannot truly empathize—to which we ourselves are, in many ways, blind.
It might well seem that empathic understanding of those with autism and Asperger's can never be more than a projection. In fact, scholarly writing about autism for much of the twentieth century, including case studies by psychoanalyst Melanie Klein and psychologist Bruno Bettelheim, may be characterized as exhibiting profound failures of both reason and emotion as well as ignorance of the limits of empathy. By contrast, recent works by Temple Grandin, who has autism, and by Oliver Sacks offer more successful representations of autism that involve research across multiple disciplines—across the borders of several branches of medicine, in addition to biography, psychology, and education, for example. As I will show, it is writing of this kind—writing that is shaped by reflection, along with a compassion formed by knowledge—that has the potential to transform ingrained structures of thought and to refigure how medical and educational institutions conceive of neurological difference. Such writing enables us to further redefine the practice of empathy as a form of engagement that seeks, both cognitively and affectively, to make sense of another's experience while preserving and respecting difference. Although this writing can never be a reliable tool for personal transformation or for changing minds, training students to generate writing that is shaped by affective and cognitive engagement, and teaching them to read such writing with understanding, may generate a newfound appreciation for the invisible barriers that impede communication, whether those barriers be between patients and members of the medical establishment, individuals with Asperger's and their teachers, or any of us—wherever we stand on the neurological spectrum—and the institutions that shape our lives.
Autism's Current Narrative
As the effort to understand autism both tests and reveals the limits of empathy, the attempt to put autism into words both tests and reveals the limits of language. Because autism remains a medical mystery, because few people with autism can explain their experience, and because this disorder is highly variable, with a range of impairments and severities across what is called the autistic continuum, any description I offer will inevitably be incomplete. That said, the place to begin, perhaps, is with diagnosis: At this point in time there is no [End Page 4] medical test for disorders on the autistic spectrum. Autism is diagnosed only through observable behaviors, which medical literature refers to as a triumvirate of disabilities: impairments of social interaction, impairments in communication, and "stereotyped" interests and behavior.8 People with autism tend to avoid eye contact and to lack expected facial, bodily, and other nonverbal expression, all of which are linked to an impaired ability to communicate. Those with the most severe form of the disorder have little or no language, but even many of those who possess language are unable to participate in the give and take of conversations because their speech is strangely mimetic, repetitive, or idiosyncratic. The play of children with autism often seems odd: it, too, can be repetitive, focused for extended periods on one object or activity, and disengaged from the play of other children. People with autism also tend to exhibit surprising reactions—they can profoundly resist unexpected events or changes in routine and can display acute sensitivity to some sensations while appearing numb to others. Another common characteristic of autism is skill with rote learning, which stands in juxtaposition to profound difficulty with tasks that require attention to context rather than to detail or with interpretation of non-literal language.
It is a commonplace of the literature on autism that "children with autism are unable to interpret the emotional states of others, failing to recognize anger, sorrow or manipulative intent."9 Autistic children can develop attachments to their parents and families, but they are generally not interested in their peers, and later, as adolescents and adults, are often too awkward to develop strong social connections.10 While this behavior can make people with autism seem aloof and eccentric, the underlying disorder is widely believed to involve a failed "theory of mind"—that is, an inability "to attribute mental states to oneself and to others and to interpret behavior in terms of mental states."11 "Theory of mind" is typically tested by asking someone to distinguish between his or her own knowledge and whether someone else might hold a different and/or false belief. In other words, what is being tested is one's ability to imagine a mind that knows or believes differently from one's own. For example, Simon Baron-Cohen describes creating a drama for his subjects with the use of two dolls, Anne and Sally. Anne puts a marble into a basket in full view of Sally. Then Sally leaves the scene, and Anne removes the marble from the basket and puts it into a box. When Sally returns, researchers ask their subjects where Sally will look for the marble. Neurotypical children and those with Down's syndrome who are over the age of three understand that [End Page 5] Sally holds a false belief that the marble is still in the basket. However, most autistic children, and some with Asperger's, think that Sally will look in the box. They cannot differentiate their own knowledge of where Anne has put the marble from the false belief held by Sally.12 They cannot, in other words, put themselves into another's place either cognitively or emotionally.
The turn in autism research toward the neurological basis of "theory of mind" marks a significant shift from mid-twentieth-century psychological theories that found the cause for autism in parental neglect of one kind or another. When autism was first recognized as a disorder in the 1940s, much of the literature speculated that it was associated with unresponsive parents and in particular with emotionally frigid mothers, who became known as "refrigerator mothers." In more recent decades, research on autism has focused not only on neurobiology but also on the genetic basis of the disease. Currently, researchers are seeking to identify the complex set of interacting genes that may cause autism, to sort through the possibility of multiple genetic paths to the disorder, and to determine possible environmental triggers.13 This shift in research is certainly welcome and urgent. In recent years, news stories and articles from sources as diverse as the New York Times and Wired magazine have reported the rising incidence of autism, which appears to have more than doubled in the last four decades.14 While epidemiological studies conservatively conclude that the current rate is around ten in 10,000 children, up from about 4.3 in 10,000 during the period from 1966–88, a recent California report about increasing developmental service caseloads estimates that the prevalence of autism in that state may have risen to more than 30 in 10,000 children.15
Even as we learn more about autism, however, it is clear that the current narrative is hardly complete. Until relatively recently, autism has been defined from the outside—by medical case studies, by scientists, and by scholars. Although autistic autobiographies are currently proliferating, especially on the Internet, many people with the condition simply do not have the language or the inclination to write or speak about their experiences, and therefore the story of what they know and who they are has long been unavailable or unrecognized.16 What gets lost in the scientific literature is attention to the inner life of the person with autism. Having surveyed texts about the definitions and etiology of the disorder, I still find it nearly impossible to imagine what it would be like to have severe autism. When I try, I imagine a world in which sensations are disordered and overwhelming, in which language cannot help to put experience into a coherent [End Page 6] narrative, in which all but the most familiar people are mysterious and incomprehensible, and in which repetition, routine, and the predictable provide the few available forms of solace. I can no more fully imagine the emotional, mental, and social lives of people with autism, especially how they understand human relationships, than I can imagine a life without the spoken word. Here is where my practice of empathy confronts its limits.
The Mindblind Past
In the mid-twentieth century, efforts to attend to the inner life of those with autism were, in fact, central to explanations of the disorder. Although the psychological focus of this era might suggest the possibility of a richer understanding of individuals with autism, practitioners such as Melanie Klein and Bruno Bettelheim produced deeply troubling interpretations of their autistic patients. Caught between the reigning theories of their era and the absence of both autistic autobiography and neurological knowledge of the disorder, their case studies reveal little insight or empathy. In Klein's 1930 essay "The Importance of Symbol Formation in the Development of the Ego," she focuses on a child named Dick, with whom she began working when he was four years old. At that time, he had little functional language, the intellect of a fifteen- to eighteen-month-old, and no evident emotional ties to his mother or his nurse. In addition, he appeared to have no interests beyond trains and stations, doors and doorknobs; little anxiety; and no ability to play or engage with his environment. Although Klein labels Dick schizophrenic, a term that served at the time for a range of neurological conditions, today a child exhibiting these behaviors would be labeled autistic.
Klein begins her study of Dick by offering a framework for normal child development. There is, she asserts, "an early stage of mental development at which sadism becomes active at all the various sources of libidinal pleasure."17 At this time, the child's "dominant aim is to possess himself of the contents of the mother's body and to destroy her by means of every weapon which sadism can command" (96). Thus, she explains, "the excess of sadism gives rise to anxiety and sets in motion the ego's earliest modes of defence" (96). She concludes her construction of normal childhood ego development by stating that this anxiety sets in motion a "mechanism of identification" by which the child equates the organs that are the source of anxiety (the "penis, [End Page 7] vagina, [and] breast") with other things on which the child then places the anxiety (97). "Thus," concludes Klein, "not only does symbolism come to be the foundation of all phantasy and sublimation but, more than that, upon it is built up the subject's relation to the outside world and to reality in general" (97–8).
By this logic, it is evident to Klein that a child who thinks literally, not symbolically, and who has not developed a settled relationship to the outside world, is profoundly delayed in psychological development, and this is the case with Dick. Rather than finding him to express "normal" sadism, she sees him as incapable of aggression and concludes that he has developed strong defenses against aggressive impulses that have locked him into a presymbolic phase; he cannot express his sadistic relation to his mother's body, and thus he cannot develop the symbolic sense that will enable him to connect with the world. This whole study is rather shocking in the context of current thinking about autism, which has shifted radically away from explanations based on ego development. Klein's construction of Dick is, from a contemporary perspective, severely weakened because she adheres to a rigid symbolic system that does not enable her to read his mind as much as it claims him as confirmation of her theory and builds a fortress of words around him. The framework available to Klein enables her to recognize only a single "theory of mind." Her theory, in other words, does not enable her to see the possibility of a spectrum of minds.
Nearly thirty years after Klein composed her case study of Dick, and more than a decade after Leo Kanner and Hans Asperger defined autism, Bruno Bettelheim published another compelling case study in Scientific American entitled "Joey: A 'Mechanical Boy,'" which, like Klein's, is driven by a theoretical argument that can only account for the autistic mind as a failure because it is not like the neurotypical mind.18 Joey's autistic withdrawal expresses itself, Bettelheim tells us, through his belief that he is a machine:
He functioned as if by remote control, run by machines of his own powerfully creative fantasy. Not only did he himself believe that he was a machine but, more remarkably, he created this impression in others. Even while he performed actions that are intrinsically human, they never appeared to be other than machine-started and executed. On the other hand, when the machine was not working we had to concentrate on recollecting his presence, for he seemed not to exist.19 [End Page 8]
Bettelheim concludes with the haunting assertion that "Joey was a child who had been robbed of his humanity" (117).
In the story of Joey's mechanical endeavors—involving every part of his daily life, from sleeping to eating to defecating (a process Bettelheim dwells upon with Freudian fervor)—what is significant to Bettelheim is less what the narrative reveals about autism than what it reveals about "emotional development in a machine age" (117). Joey, he decides, finds it too painful to be human, a disconcerting judgment. Bettelheim thinks Joey has sublimated his humanity because of his "detached" and "indifferent" mother (118), whom Bettelheim accuses of completely ignoring her son, and also because he is a child of his culture. In his major theoretical work on autism, The Empty Fortress, Bettelheim notoriously maintains that emotionally withdrawn and unloving parents, particularly mothers, are largely responsible for autism. He asserts that "the precipitating factor in infantile autism is the parent's wish that his child should not exist."20 In Joey's case, however, Bettelheim finds the origin of Joey's disorder in the current era of material excess: "At the extreme where utter scarcity reigns," he asserts, "the forming of relationships is certainly hampered. But our society of mechanized plenty often makes for equal difficulties in a child's learning to relate" (126). Parents in earlier years, he says, expended effort and took pleasure in being able to give to their children, which in turn enabled the children to develop "a sense of personal worth" and thus a foundation for social relations (126). He warns, however, that when providing comfort becomes too easy in times of plenty, parents get no pleasure from giving, and children develop no sense of worth.21 In the service of this moral about how our attachment to the material has left us starved for humanity, Bettelheim weaves Joey into a metaphor-laden, machine-age fairy tale about how our attachment to the material world has left us starved for humanity and displaced true empathy.
As a fairy tale, the story may seem uplifting. Readers receive confirmation of the importance of parental love and care, the dangers of materialism, and even the risks of early toilet training. Ultimately, however, when Bettelheim tells us at the end of the article that Joey made a Memorial Day float with the slogan "Feelings are more important than anything under the sun" (127), it appears Joey has been transformed for the purposes of a moral and medical fiction, as Dick was transformed in Klein's earlier case study. Thus, Bettelheim's text demonstrates again the distortions we generate when we use illness as a metaphor to interpret and write about the unknowable or unreachable realm of another's experience. [End Page 9]
These distortions ultimately result in a false etiology for the disorder. In The Empty Fortress, Bettelheim argues that autism is parallel to the "extinction of feeling" and effacement of self suffered by some concentration camp prisoners.22 To introduce this analogy, he writes, "In the German concentration camps I witnessed with utter disbelief the nonreacting of certain prisoners to their most cruel experience" (57). He continues, making the link to autism, "I did not know and would not have believed that I would observe similar behavior in the most benign of therapeutic environments, because of what children had experienced in the past" (57). The prisoners who felt helpless and doomed "deteriorated to near autistic behavior when the feeling of doom penetrated so deep that it brought the added conviction of imminent death" (65). Children with autism, he believes, have an "inner reality" comparable to the "external reality" of the prisoners and, like them, direct all their energy into a defensive withdrawal (75). The absence of language, he claims, is a "defense against emotional pain or any further depletion of the self" (59). Thus, he concludes that "infantile autism is a state of mind that develops in reaction to feeling oneself in an extreme situation, entirely without hope" (68). Here we have an extraordinary symbolic equation in which Bettelheim draws on his own experience and his formative psychological observation of reactions to brutal mistreatment. In order to understand human behavior that defies explanation, Bettelheim turns to the only experience he can compare to what he observes. The analogy inspires him. It enables him to begin, he thinks, to understand the disease. And his memory of these withdrawn men, avoided by the other prisoners "as if in fear of contagion" (65), helps him to think about their experience and autism in terms with which he can clearly identify.
As moving as Bettelheim's elaborate analogy may be, it is like the cancer and AIDS metaphors Susan Sontag argues against in Illness as Metaphor and AIDS and Its Metaphors: it distorts more than it enlightens, for it causes Bettelheim to assume analogous causes—that people with autism, like concentration camp prisoners, suffered from abuse, and that the absence of language is a reaction to helplessness and hopelessness. He does not recognize that autism is caused by neurological difference; instead, he assumes that capacities for communication and empathy are essential. His analogy seems to be informed by such pain and such an effort to imagine the experience of another, but with few medical facts to turn to, Bettelheim's reliance on his own experience and the limitations of a Freudian framework gives him an incomplete picture of the minds he seeks to understand. Bettelheim's problematic story [End Page 10] about Joey appears, in the end, to illustrate the dangers of a version of empathy in which he imposes his own experience on his subject. Bettelheim's relation to Joey in no way approaches the version of empathy defined by Kaplan, which would involve attending to Joey's experience while also respecting his difference. Without taking the critical step of preserving difference, Bettelheim ignores empathy's limits, and this ultimately contributes to his own version of mindblindness—the inability to understand an autistic mind.
Empathy, Compassion, and Revisions of Autism
In my discussion of Bettelheim and Klein, I have attended to the problem of empathy as it appears in case studies and to the ways in which a doctor may misjudge the limits of his or her perspective in an effort to understand a patient. My discussion of these problems might seem at odds with current exchanges about the value of empathy that are taking place in the medical humanities. It may, in fact, come as a surprise to some in this field, and to the medical profession more generally, that contemporary rhetoricians would likely see Klein's and Bettelheim's texts as supporting an argument against empathy. In "Rhetorics of Proximity: Empathy in Temple Grandin and Cornel West," rhetorician Dennis Lynch observes that although empathy has historically been central to rhetorical studies, more recently it "has been scrutinized, critiqued, and all but abandoned" by those who maintain that empathetic rhetoric most often requires those without power to divide themselves between the speaker or writer and their own marginalized selves.23 The most common conception of empathy, Lynch observes, the "desire to step into the shoes of someone else," suggests that all empathy is "dependent on the physical, bodily displacement of the other" (6). That is, when those in less powerful positions are coerced to empathize with those who have more power, empathy reveals itself to possess a political dimension that perpetuates, indeed magnifies, existing differences in power while erasing other personal and cultural differences.24
Medical practitioners possess the power of expertise over their patients, and it is therefore essential for them to consider the criticism leveled at empathy by post-structuralist theory, to recognize its unreliability and potential for abuse, and to examine with care the ways in which the difference in power between doctor and patient creates the conditions for displacement and coercion. While I believe that this [End Page 11] critique of empathy expresses an appropriate sensitivity to the complex meanings of social interactions, I remain concerned that if we banish the practice of empathy from our professional encounters, we will abandon attempts to understand one another. Thus, I am relieved that Lynch, who seeks to rescue empathy from the trash heap of rhetoric, offers a partial solution to the problem of the displacement caused by empathy, one that is applicable both to writing about medicine and to medical practice. We should attend, he says, to writing that "keeps the body squarely at the center of rhetorical exchange," writing that works "[b]y soliciting empathy from us, but by also emphasizing certain of the problems with empathy" (10). When Lynch insists that communication keep the body at its center, he reminds us not to assume that language can transport us into another's experience; there will always be differences that cannot be erased, and some of those differences, he suggests, are grounded in the particulars of individual, embodied experience—an experience that includes race, sex, health, or illness, as well as one's place on the neurological spectrum.
Lynch offers examples of the kind of writing we should attend to in Cornel West's speech"Race Matters" and, more important for my argument, Temple Grandin's second autobiography, Thinking in Pictures, and Other Reports from My Life with Autism. Both Grandin's and West's texts insist on the difference of each author's own embodied, cultural experience. Each invites empathy, but each also draws attention to the possibilities and limits of emotional identification. West's use of empathy, for instance, asks listeners and readers to reflect on their raced selves and bodies and the history and social dynamics that complicate our understandings of ourselves and race. Lynch writes that West "maneuver[s] us into difficult positions that have the potential, through stress, to encourage us to change/refuse who we are" (17). Grandin's autobiography similarly elicits empathy from her readers by inviting them into her world and representing herself as being on a continuum of humanity with them at the same time that she offers examples that demonstrate they can never truly understand the difference of her mind. In the first chapter of Thinking in Pictures, for instance, Grandin begins by declaring that images are her natural cognitive mode—"full-color movies, complete with sound, which run like a VCR tape in my head"— and that, in contrast, words are "like a second language," a language that will always be foreign, will always require translation back into pictures.25 Although Grandin offers the analogy between language and video, and although she spends the early pages of her book describing in words how she thinks entirely [End Page 12] visually as she designs livestock equipment, moments in the text make clear that her narrative can only be an approximation of her way of being. She points out, for instance, that the images with which she thinks are always specific, never general: to her, there is no generalized image of a dog, or even a Great Dane. Instead, she sees specific Great Danes, each of which is arranged in strict chronological order in her memory. Abstract concepts present a particular challenge. Thus, the Lord's Prayer was incomprehensible to her until she "broke it down into specific visual images" (33). In this prayer, "the power and the glory," for instance, makes sense only as a "semicircular rainbow and an electric tower," and "thy will be done" as an image of "God throwing a lightning bolt" (33). Even more foreign is her assertion that, because of her visual orientation, "certain verb conjugations, such as 'to be,' are absolutely meaningless" (31). Because Grandin thinks in pictures, her relationship to language must remain deeply alien to those who think linguistically—deeply alien, that is, to most of her readers.
In exploring how Grandin's and West's texts work rhetorically, Lynch's goal is to complicate the critique leveled at empathy by introducing the concept of rhetorics of proximity. Such rhetorics, he argues, offer a solution to the dangers of empathy because they accept understanding as approximate and partial, rather than transparent and total. According to Lynch, these texts "seduce us into ambiguous social spaces," draw attention to the obstacles to valid empathy, and then "us[e] those obstacles as possibilities for social exchange rather than as reasons for refusing interaction" (11). Rhetorics of proximity, in other words, reinvigorate the rhetorical practice of empathy while recognizing that it is always incomplete and in need of careful exploration and examination. Such rhetorics take the dangers to which empathy is prone and exploit these to shape a productive social exchange.26 Grandin's writing exemplifies this practice. According to Lynch:
She wants us to become more familiar with obstinate bodies, with irreducible complexity, and with the simple act of refusal, with a "no" that does not have to end interaction forever but that admits that no one understands exactly what is happening in every situation and that no one needs to assert authority in every situation.(14)
I am convinced that the concept of rhetorics of proximity can provide a way out of the critical bind that has so successfully revealed the problems of understanding others when difference is ever-present, layered, and multiple. And yet, I wonder about the two authors Lynch [End Page 13] has chosen to focus on, both of whom insist on making their embodied experiences of autism and race central to their interactions with their audiences. The rhetorics of proximity suggest that thinking through particularized, embodied experience is the only legitimate way to elicit or exercise empathy. If so, however, where does that leave those with autism who cannot narrate their own experiences? This form of critical empathy depends, by definition, on language. Rhetorics of proximity also exclude medical practitioners or writers who seek to understand or give voice to ideas informed by experiences other than their own. Lynch's rhetorics, for all their promise, impose new limits on empathy. They do not provide a way to think about the possibility of empathetic or compassionate medical practice, teaching, or scholarship.
Oliver Sacks and the Composition of Proximity
As I consider the question of how best to define empathy, as well as the question of whether empathy can be practiced ethically across divides of difference, I have found an alternate model in another text about Temple Grandin—Oliver Sacks's literary case study "An Anthropologist on Mars." Sacks has, throughout his career, represented writing and narrative as central to making sense of the strange and disorienting world of neurological disorders. Because Sacks wants his readers to understand autism beyond the clinical diagnosis, and because he recognizes that "no two people with autism are the same," he makes the surprising claim that "if we hope to understand the autistic individual, nothing less than a total biography will do."27 In composing a biographical case study, Sacks does not create a rhetorics of proximity with his own readers but rather narrates his own rhetorical proximity to Grandin as he spends a weekend visiting and interviewing her, listening, learning, and evaluating her understanding of autism against his own expertise in neurology. He recognizes that she remains a puzzle to him (as he does to her), but she is a puzzle well worth engaging. In the end, Sacks shapes Grandin's public and private lives and thoughts into a story more coherent and, I would say, even more compelling than Grandin's own autobiography.
If we value rhetorical proximity, Sacks's essay offers diminished access to an understanding of the "otherness" of autism. His readers, unlike those of Grandin's autobiography, do not negotiate directly with the unfamiliar body from which a challenging voice emanates. And yet, I would like to argue that there is something else of value that [End Page 14] takes place in Sacks's text—an enactment not of Lynch's rhetorics of proximity or of conventional empathy, but rather of an informed and active compassion. Sacks's essay shows that thoughtful, researched, even scholarly engagement that does not overvalue any single framework can, like Grandin's text, enable us to learn about others. His medically informed account also generates the possibility of moving beyond reaction to action that is shaped by care and knowledge.
To define what I mean by Sacks's informed and active compassion, I want to turn for a moment to the work of philosopher Martha Nussbaum, who writes extensively about compassion in Upheavals of Thought: The Intelligence of Emotions. In this text she carefully differentiates empathy from compassion, maintaining that empathy—"an imaginative restructuring of another person's experience"—is emotionally neutral and does not necessarily involve any sympathy for the pain of another.28 Compassion, by contrast, "seems more intense and suggests a greater degree of suffering, both on the part of the afflicted person and on the part of the person having the emotion" (302). Compassion involves bringing new understanding into oneself, where the response becomes bodily, where it becomes, Nussbaum says, with reference to Aristotle's definition of compassion, "a particular type of pain" (325). She admits that compassion is fallible, inconsistent, and incomplete. Like empathy, it is not a reliable vehicle for truth; we cannot depend on its accuracy even if we suspect that it is embedded in our ways of thinking. Those who have a capacity for compassion need to learn to use it, in other words, with care, because it does not guarantee clear thinking and valid argument. Nevertheless, Nussbaum argues, "Despite its potential for unevenness and partiality . . . compassion can be an invaluable way of extending our ethical awareness and of understanding the human meaning of events and policies" (14). In her view, informed compassion is an important foundation for deliberation in public life. Compassion and reason are thus not binary poles, but complementary functions as we seek to solve complex problems involving the relation of people to institutions such as the state, law, medicine, and education.
Applying Nussbaum's ideas to Sacks, I would argue that Sacks's thoughtful, researched, multidisciplinary engagement creates the conditions for him to have a complex experience of connection with both Grandin and his readers. His compassion evokes empathy, but complicates it, as Nussbaum does, with a greater degree of suffering, analytical understanding, and awareness of compassion's limits. As an experienced writer and physician, for instance, Sacks must understand [End Page 15] that his interpretation of Grandin will not be wholly true to her experience. He must also be aware that writing that seeks to intervene in established patterns of thought cannot do this work predictably or with ease—that writing cannot heal the physical or eliminate the grinding difficulties of life. But his work demonstrates his resolve that we need to engage anyway, to confront those limits and use arguments to begin the work of changing minds—our own included.
A fundamental element of Sacks's compassionate engagement is that he brings to the task of understanding autism a negotiated knowledge. His knowledge is negotiated because he builds it in dialogue with his subject, Grandin, and also because he mediates between areas of scholarly inquiry that are not typically thought to have any bearing on one another. His essay bridges, for instance, biography and neurology, the study of mind and body, and, perhaps most surprisingly, scientific inquiry and spiritual questioning. His work is interdisciplinary but constitutes something slightly different from most interdisciplinary writing in that his sources are not limited by the conventions or methodologies of any discipline or set of disciplines. Instead, Sacks brings to bear the breadth of his knowledge and experience, as well as his innovative talents and personal quirks, to join the story of the body and the life of his subject. The complexity of the neurological puzzle he is trying to solve challenges him to create a composition of proximity.
The most obvious examples of Sacks's interdisciplinary composition of proximity are the moments when he embeds medical information into the biographical narrative—sometimes directly, occasionally with parenthetical comments, most discretely with footnotes. For me, one of the most interesting moments occurs when Sacks reflects that he was surprised before he met Grandin that a person with autism could have written an autobiography. It seemed, he says, "a contradiction in terms."29 He noted that Emergence: Labeled Autistic, Grandin's first autobiography, which she wrote with a journalist, had "coherence," "poignancy," and an often "'normal' tone" that perhaps could be attributed to her collaborator (253). And yet, as an experienced writer, Sacks reviews her papers and her autobiographical articles and finds "a detail and consistency, a directness, that changed [his] mind" (253). He then appends to this literary observation a neurological footnote explaining that within the appearance of a normal voice, there are "peculiar narrational gaps and discontinuities, sudden, perplexing changes of topic" brought about, according to Happé, by Grandin's failure to recognize that her reader does not share her background knowledge—that is, by her failure to recognize that her readers are not [End Page 16] mind readers (253n4). This example, it seems, puts a bit of pressure on Lynch's rhetorics of proximity. While it is true that Grandin's text invites readers into ambiguous interactions, at the same time eliciting empathy and making readers aware of the limits of their understanding of her mind, Sacks's note suggests the degree to which this rhetorical stance may be a product of her autism—not intentional at all, not a rhetorical choice she has made. To a greater degree than we may be comfortable with, her writing is shaped by her neurology. Sacks implies that the way Grandin's brain functions makes her only able to produce a text with puzzling gaps that disrupt the reader's connection with her perspective. She cannot help but embed her neurological story in the very voice of her autobiography.
Ultimately, Sacks's openness to learning from other people and other realms of knowledge and his openness to revising his own theory of the autistic mind allow his essay to reach beyond Klein's and Bettelheim's more insular approaches to solving the puzzle of autism. Granted, Klein and Bettelheim did not have access to the scientific knowledge that upholds the integrity of Sacks's text, but they also prized narrative coherence over appreciation for the complexity of the problem they were studying and, as the flaws in their interpretations demonstrate, they did not reflect sufficiently on those moments of tension when their patients' experience chafed against their rigid explanatory structures. Sacks's work also complicates the relation between expert and amateur, physician and patient. At times, he holds to his medical expertise, but often he asks Grandin open questions and is prepared for unsettling answers that alter his conceptions of autism. His simple question about the night sky—"Do you get a feeling of its grandeur?"—invites Grandin to reflect upon death, morality, divine judgment, and her scientific notion of God (294). Sacks had never before considered the spiritual lives of people with autism and this possibility alters his conception of autistic minds. Another time, Sacks is resistant when Grandin claims that the differences in her "emotional circuit" mean she has no unconscious, no repressed thoughts: "Either you are incorrect or there is an almost unimaginable difference of psychic structure. Repression is universal in human beings" (286–7). And then he thinks again. He thinks of his experience with patients suffering from illnesses or injuries to the brain and he revises his reaction, appreciating anew the differences that neurology makes. [End Page 17]
Learning and Responsiveness
Sacks's willingness to learn from Grandin and thus to rethink his own knowledge and position is a defining characteristic of his approach in "An Anthropologist on Mars." Is his interaction with Grandin best understood, however, as an expression of compassion? Is it, by contrast, more akin to the form of empathy defined by Kaplan—an affective connection that is informed by analysis? Or are the words compassion and empathy inadequate because they have become overburdened by implications of appropriation, displacement, arrogance, pity, and erasure? Perhaps learning that is characterized by reciprocity and negotiation, by a movement from the self to another and back, requires a new term. One possible term that suggests both the movement between self and another and the distance that remains between them is responsiveness. Responsiveness indicates the affective engagement of empathy, the thoughtfulness and action made possible by compassion, and the interplay between the writer and his subject that is revealed in Sacks's work.
Sacks's responsiveness demonstrates that we can begin to understand one another across divides of difference, and thus it has implications beyond his essay. It points to a clinical practice in which attuned, respectful listening and analytical attention to patients' words, behavior, affect, and silence are central, and it points, as well, to the benefits for the patient of a relationship in which knowledge is shared and consciously negotiated. This is not to say that Sacks's essay provides a template for ideal medical engagement or teaching. After all, the responsiveness exemplified in "An Anthropologist on Mars" is only possible because the person in Sacks's proximity is highly verbal—and Grandin certainly represents an exceptional example of autism. It is also the case that there are people—some with autism, some without—who deflect empathy and engagement and that there are others—some doctors, some not—who are disinclined to affective understanding, even in situations of proximity. In the spectrum of humanity, every person cannot become ideally compassionate, nor will every person want to receive compassion. Thus, in a clinical setting, as in a classroom, multiple empathic scales are in play that shape and limit the possibility of affective and cognitive understanding. Teachers and health-care providers, however, are always faced with the challenge of engaging with and understanding difference. Rather than resigning ourselves to the impossibility of complete understanding of others, a more productive response would be to find ways to create the conditions for responsive learning. [End Page 18]
And so, I would like to return to my classroom and to my student Gregory. Assessing Gregory's educational story is a challenge because narratives of teaching, like the case studies by Klein and Bettelheim, are often shaped by the pressure to present a subject who is transformed and healed by the knowledge and compassion of the professional. Thus, in both educational and medical realms, our narrative conventions can lure us into forgetting that there remains an irreducible difference between the experience of the subject and the revisable discourse of the narrator. With this danger in mind, it is evident that Gregory's story is not one of unequivocal educational success. Indeed, I have never confronted the limits of teaching so profoundly as when I worked with Gregory. Not surprisingly, he did not learn to write and think in the same way as the other students, or with as much normative success. Once he defined his position on a matter, he appeared to find it impossible to independently locate and examine assumptions and counterarguments or to complicate his original stance because doing so required being able to imagine a perspective different from his own. Thus, in early conferences about his drafts, I felt as if I were giving him a "theory of mind" test, asking him to think in a way that he simply could not. In addition, because he could not comprehend what his readers might expect or think, he struggled to understand on his own or work within conventions. He had difficulty, for instance, recognizing when he offered too much or too little background; he did not notice when he left his argument behind to go on a tangent; he omitted the transitions that might have eased a reader from one idea, one paragraph, one sentence to the next. He struggled, as did I, with the fundamental tension between what I was supposed to teach and what he was capable of learning. His definitive neurological reality could not be changed by my concern or my educational practice. Instead, I had to figure out how to redefine my goals and to teach around the cognitive obstacles.
I finally achieved some level of success because I found ways to respond to Gregory's individual perspective and cognitive style. This occurred because I gradually learned to listen and to understand at least some of what I heard. I realized that Gregory often showed me what would work best for him. His requests for extra conferences, his detailed queries about my written comments, his regular e-mails asking me to look at this or that section of a new draft at first seemed merely obsessive, but they also expressed a need to literalize the audience that he could not imagine. Thus, in our conferences, I began to narrate my experience as a reader. I coached him as he took notes [End Page 19] on my observations and charted plans for revision. I also realized that the only way he would be able to produce academic essays would be by developing an explicit system, so I gave him mechanical rules to follow about organizing his essays and paragraphs that I would have been reluctant to use with other students. Because I could not expect Gregory to internalize a sense of audience, I worked with him to develop a process that would enable him to write in the future. Understanding an audience will never be an intuitive or easy task for him, so his writing and revising process must involve real readers—professors, teaching assistants, tutors, others—who can review his drafts to help him find the problems that he cannot see on his own. Working in this way, Gregory, who had seemed impossible to teach at the beginning of the semester, finished the term performing solidly in the middle of the class.
In the end, this is not a story of profound personal or institutional transformation. It is, I believe, better understood as a story about the possibilities afforded by the practice of responsiveness. In the particular context of a writing class, this means that Gregory learned that responding to an audience is essential to the task of writing. At the same time, I learned to become open to learning from, not simply about, an audience, if the word audience can mean an interlocutor, a reader, or a student. Such responsiveness also defines the core of Sacks's essay, where he negotiates with multiple audiences, especially those readers whose thinking about autism he seeks to transform. As an author and a neurological authority, he demonstrates how important it is for him to learn from Grandin, to be surprised by her, even awed by her, and to respect her difference as he seeks to understand her. Ultimately, in institutional settings such as the classroom or doctor's office, the reciprocal engagement that Sacks demonstrates will never be a panacea for the disruption to communication caused by difference. It does not promise total clarity and insight. But his practice of responsiveness does suggest that the effort to make a connection can be rewarded and that we should therefore not resign ourselves to utter blindness about other minds.
Ann Jurecic is an assistant professor in the Rutgers University English Department, where she teaches literature and medicine, as well as writing. She is at work on a book entitled Composing Illness that examines literary accounts of disease and disorder, attending in particular to moments when writing enables the relationship between medical discourse and patient experience to become more reciprocal and fluid. Professor Jurecic has recently published in the journal Pedagogy.
1. See Frith and Happé, "Language and Communication in Autistic Disorders."
2. See Spiro et al., Empathy and the Practice of Medicine.
3. Halpern, "Empathy," 161-3. See also Halpern's From Detached Concern to Empathy. [End Page 20]
4. Ibid., 162.
5. Alexandra G. Kaplan, "Male or Female Psychotherapists for Women: New Formulations," in Women's Growth in Connection: Writings from the Stone Center, ed. Judith V. Jordan et al. (New York: Guilford Press, 1991), 273, quoted in More and Milligan, introduction to The Empathic Practitioner, 3.
6. Tager-Flusberg, Baron-Cohen, and Cohen, "An Introduction to the Debate," 3.
7. See Baron-Cohen, Mindblindess.
8. See Diagnostic and Statistical Manual of Mental Disorders, 66-7.
9. Rodier, "The Early Origins of Autism," 56.
10. See Folstein and Rosen-Sheidley, "Genetics of Autism," 944.
11. Baron-Cohen, Mindblindness, 55.
12. See Baron-Cohen, Mindblindness, 69-72.
13. See Turner, Barnby, and Bailey, "Genetic Clues to the Biological Basis of Autism."
14. See, for instance, Blakeslee, "Autism Diagnoses Double in California"; and Silberman, "The Geek Syndrome."
15. See Blakeslee; Frombonne, "Epidemiological Trends in Rates of Autism," S4; and Frombonne, "The Epidemiology of Autism," 777.
16. The most popular recent autistic autobiographies are by Temple Grandin and Donna Williams. Grandin has two autobiographies, Emergence: Labeled Autistic and Thinking in Pictures, and Other Reports from My Life with Autism. Williams also has two autobiographies, Nobody Nowhere: The Extraordinary Autobiography of an Autistic and Somebody Somewhere, Breaking Free from the World of Autism. Lists of other autobiographies and links to online autobiographies are available at Kathleen Seidel's "Autistic Autobiography Online."
17. Klein, "The Importance of Symbol Formation in the Development of the Ego," 95-6. Subsequent references are cited parenthetically in the text.
18. It is worth explaining why so many of the examples I have written about examine boys. Autism affects boys at a much higher rate than it affects girls, approximately 3 or 4:1 among those with IQs higher than 50. See Bauman and Kemper, The Neurobiology of Autism, 32. There are some interesting hypotheses about why this is so, including speculation about excess prenatal levels of testosterone and even a controversial theory, drawing on the early work of Hans Asperger in the 1940s, that autism is an expression of "extreme maleness." According to Baron-Cohen, "male" brains (whether these brains belong to men or to women) are better at systematizing than empathizing. Autism, according to his argument, is an extreme version of the male cognitive profile. See Baron-Cohen, "The Extreme Male Brain Theory of Autism."
19. Bettelheim, "Joey," 117. Subsequent references are cited parenthetically in the text.
20. Bettelheim, The Empty Fortress, 125.
21. See Bettelheim, "Joey," 126.
22. Bettelheim, The Empty Fortress, 57. Subsequent references are cited parenthetically in the text.
23. Lynch, "Rhetorics of Proximity," 10. Subsequent references are cited parenthetically in the text. Lynch's article offers a quick and useful review of the current conversation in rhetoric about these issues. Among the critics whose work he cites as critiquing empathy from a "poststructuralist, postcolonial, or postmodern" perspective are Susan Jarrett, Lester Faigley, and Raymie E. McKerrow, along with James Zappen, Lisa Ede, Jim Corder, and Phyllis Lassner (6).
24. See Lynch, 7.
25. Grandin, Thinking in Pictures, 19. Subsequent references are cited parenthetically in the text.
26. See Lynch, 20.
27. Sacks, "An Anthropologist on Mars," 250. [End Page 21]
28. Nussbaum, Upheavals of Thought, 302. Subsequent references are cited parenthetically in the text.
29. Sacks, 253. Subsequent references are cited parenthetically in the text.