Saturday, September 19, 2015

Subtext of "The Autism Spectrum"

I was free associating to public radio a while ago as I listened to Terry Gross interviewing actor Timothy Spall on playing J.M.W. Turner (1775-1851).  Turner was an English artist in the 1800s, renowned for his use of color and light.  His painting above from 1839 was voted Britain's favorite painting in a 2005 BBC Radio poll.  I placed it here to illustrate these techniques that are visible looking toward the sun as it illuminates the cloud cover and some outlines at the horizon as it sets.  Some of the technical aspects of his painting that distinguish him from his contemporaries include the use of a white primer, limited use of underdrawing (sketching before the paint is applied), painting fast with a hard brush and palette knife, and parsimonious use of pigments (see reference 1 for details).  Spall studied art for two years in preparation for this role and was eventually able to recreate a Turner painter.  He describes Turner as possibly one of the greatest landscape painters of all time.  He also teaches how words change in meaning over time when describing how the sublime art movement grew out of the romantic and had as its goal "to capture the beauty of nature, as well as its terror and its horror."

The actual film Mr. Turner as described in the Fresh Air episode seemed somewhat different than the one described.  It did cover the last two decades of Turner's life.  In it we meet Turner, his ex-wife and two adult daughters, his housekeeper, several of his colleagues, and a woman who he meets when she is married and marries when her husband dies.  We see enough of these relationships to develop an impression of what may be going on.  The relationships are set against a visually stunning backdrop of the cinematographer shooting Turner as he travels to sketch seascapes and eventually convert them to paintings.  In many cases, such as the painting at the top of the post we see the scene blend into the painting.  The cinematography of these scenes is some of the best that I have seen anywhere.

I think the key about whether you might enjoy the film or not depends a lot on whether you can appreciate Turner's eccentricities and the attempt at portraying the depth of his character.  He certainly does things that many would find repugnant.  The impression that I had about his relationship to his family was that he had abandoned them.  His ex-wife was somewhat intrusive in attempting to get him to show some interest.  She did not seem to impress him in the least and he would typically walk away.  He did not attend the funeral of his daughter and when asked told people that he had no children, while his father had a facial expression of disapproval in the background. On the other hand he did marry a widow and stayed with her until his death.  Along the way he had a sexual relationship with his housekeeper.  There was one scene of perfunctory sexual intercourse between Turner and his housekeeper.  No words were spoken between them during that scene or at any point to suggest that they had any emotional intimacy but the actress in this case projects a strong sense of caring for him and eventually travels to see him when he is dying in his new home.  She appears saddened when learning he has a new wife and walks away without seeing him.

Throughout the film Turner communicates at times with a series of grunts, even though he has communication skills as good as anyone else in the film.  He has a characteristically gruff and unkempt appearance and only seems to smile when he is in the midst of a deathbed delirium.  I think that presentation is what led Terry Gross to ask the question about whether he might be on the autism spectrum and Spall's excellent response on subtext.  Spall speaks to the fact that he portrayed Turner's inner anguish after hearing that one of his children had died despite his overtly dismissive relationship with them.  He expands on the relationship with his housekeeper and what that means.  He describes his intellect as implosive as a reason for the communication in grunts at times, even though he could be quite articulate at others.

That response was a great one in so many ways.  It explodes the idea that observable behaviors mean much of anything out of context.  If I am gruff appearing or eccentric does that mean much of anything by itself?  Probably not.  Being gruff or eccentric appearing is not really a risk factor for seeing a psychiatrist and it is unlikely that those features mean much of anything.  And what about the communication style and the frequent grunting?  The first time I heard it I had the impression that it was the equivalent of the modern day English expression "oi"  or the American expression "hey".    I did not see it as the typical communication problems in autism.  It also speaks to the larger headlines of famous people who either think they are "on the spectrum" or somebody else thinks there are.  That comes from a number of sources - not the least of which is the popular notion that reading the DSM without being trained in psychopathology means much of anything.  Should a person get evaluated for congestive heart failure by a doctor who has just pulled up an internet site that lists the diagnostic criteria for congestive heart failure or is it better to see a doctor who has made the diagnosis many times, and by learning those patters of illness can successfully parse cases that are in the grey zone (eg. is this congestive heart failure or asthma?).

That is the ultimate value of Spall's comment on subtext.  There is not a lot that is explicitly known about this character in the film.  Certainly nowhere near as much explicit content as Spall discusses in his interview.  And yet he is pointing out that there is something implicitly there to suggest that Turner is not autistic (whatever that might be).  One of the many misconceptions about psychiatrists is that we want to diagnose everyone with some kind of disorder.  A substantial number of the people I have seen over the years want to know that they don't have a problem.  They either ask me up front or at the end:  "So do you think I have (bipolar disorder, Alzheimer's Disease, alcoholism, OCD, borderline personality disorder, etc.)?"  They are relieved that I know the subtext and can say no.  Some people will just ask the generic question: "Do you think I am crazy?" and I explain why that is not a relevant question.  In many cases I just have to tell people:  "I know that you are being treated for this disorder (usually bipolar disorder or ADHD), but there is no real evidence that you have it.  I have treated hundreds of people with this problem and there are a number of reasons why you don't have it.  And by the way, if you don't have the disorder - I would not recommend that you take medications for the disorder."  In rare cases I will see a person who asks a very specific question: "I have been in psychotherapy for 5 years now.  That is a long time.  Do I need to keep going?" and I am obliged to give them my opinion.

Often the observations have to do with non-verbal behavior like Sprall's comment on Turner.  What does silence mean from one meeting to the next?  In one meeting it means tacit unanimous agreement.  In the other it means just the opposite.  What happens if I see a young man thrashing about on the floor and the people around him are panicked and implore me to "Do something doctor?"  Instead of calling a code I reach out and pull him up off the floor and he stands there looking mildly anxious.  And what about that anxious patient who has a piece of pipe in his hands and says: "Do you want a piece of this?"  Instead of confronting him and telling him what to do, I explain what is really happening here - he is scaring the hell out of people (including me) and it is unlikely that an old man with glasses is going to fight him or anybody else.  He apologizes and drops the pipe.  I can recall walking into a gas station in Northern Wisconsin on brisk winter morning at about 7 AM.  A large man crashed into me and my wife right in the front doorway.  I grabbed him by the jacket, he went limp and I lowered him to the ground.  "What are you doing?  What's wrong with him?" my wife asked excitedly.  He was drunk at 7AM and in a stupor on the ground.  In all of these situations things are not what they seem to be.  We all act quickly based on limited information and the chances for error are great.

One of the more critical subtexts is what happens when a person you know very well appears to be different in some subtle way but there is no clear way to describe it.  The standard mental status exam including their cognitive screening turns out to be a very blunt instrument in this situation.  I have talked with people and done complete cognitive screening and when I see them again, they have no recollection of ever seeing me again despite a perfect score on the cognitive exam.  The only differentiating points were the smell of whiskey in the air and a coarsening of affect.  In other cases, a person may deny all problems including the ones that are the focus of treatment and exhibit a slight clouding of consciousness as a prelude to serotonin syndrome or neuroleptic malignant syndrome.

All of that commentary, representing a significant part of psychiatric practice has to do with subtext and not reading a diagnostic manual.  I thank Timothy Spall for his response on the issue of the Autism Spectrum, because it is really about a lot more than that.  I have always been impressed with the observations of artists and my English professors in looking at theories of human behavior and the applied metaphors.  It is also an indication of how difficult it is to be an actor.

George Dawson, MD, DFAPA                


1:  Antonino Cosentino.  Cultural Heritage Science Open Source.  J. M. W. Turner (1775–1851).  Technical Art Examination.  March 24, 2014.

2:  Terry Gross.  Fresh Air.  Timothy Spall Takes On Painter J.M.W. Turner A "Master of the Sublime."  December 14, 2014.  Be sure to listen to the audio to appreciate Spall's voice and accent in this role.

Supplementary 1:

The painting here is: "The Fighting Temeraire tugged to her last berth to be broken up" by J.M.W. Turner.  It was downloaded from the WikiArt web site that advises that the copyright expired because the painter died more than 70 years ago.

Supplementary 2:

Don't try any of the interventions described in this post at home.  They are likely to backfire.

Supplementary 3:

Definition of Subtext from

"Subtext or undertone is content of a book, play, musical work, film, video game, or television series which is not announced explicitly by the characters (or author) but is implicit or becomes something understood by the observer of the work as the production unfolds.  Subtext can also refer to the thoughts and motives of the characters which are only covered in an aside. ...."

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