Autistic patient wants to get a PhD in their current special interest?

[futureapppsy2]

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I’m working in a clinical setting that works with patients with mental illness on vocational goals, for context. The patient is in his 30s and was recently diagnosed with autism. The patient has previously been diagnosed with a number of psych disorders, though the team is still trying to sort out which of those dxes are better explained by the autism dx and which are legit co-occurring dxes. He wants to get a PhD in his current special interest (a niche part of a humanities field), and both the patient and his wife admit to his special interests changing frequently (every couple of months usually, sometimes every couple of years)—he’ll be completely obsessed with something for a while and then suddenly lose all interest in it and move on to something else. Despite this pattern, he’s sure getting a PhD will be perfect, as it will allow him to focus on his special interest in a goal-directed way. I’m worried what might happen if he suddenly loses that interest midway through the program. I know a fair amount of autistic faculty and PhDs, but they’ve generally stayed away from getting PhDs related to their special interests and pursued those on the side, in part because of that concern and in part because they didn’t want the pressure to monetize their special interest.

Any thoughts?

 

[Sanman]

A PhD in anything sounds like a long term goal for this individual. The work likely should be focusing on short-term goals (next 6 mths). What are the initial steps they need to take in furtherance of this goal? A job with Autistic individuals? Research job? College degree? Work on the short term goals and re-evaluate periodically. Long term goals can be re-evaluated once they reach the next level of progress. If they never reach the next interim goal, the phD was a pipedream anyway.

 

[futureapppsy2]

A PhD in anything sounds like a long term goal for this individual. The work likely should be focusing on short-term goals (next 6 mths). What are the initial steps they need to take in furtherance of this goal? A job with Autistic individuals? Research job? College degree? Work on the short term goals and re-evaluate periodically. Long term goals can be re-evaluated once they reach the next level of progress. If they never reach the next interim goal, the phD was a pipedream anyway.

He’s already done the BA part (finished recently after a long interruption) and applied to PhD programs, so he’s academically qualified. He’s coming to us because he wants us to support/fund it as a means to enter academia as a profession, but I’m not sure it’s feasible long-term based on his history of losing special interests when he admits that this subject is exactly that (His work history is mixed—had a good record of job retention in his 20s but more recent jobs were much rockier).

 

[R. Matey]

He’s already done the BA part (finished recently after a long interruption) and applied to PhD programs, so he’s academically qualified. He’s coming to us because he wants us to support/fund it as a means to enter academia as a profession, but I’m not sure it’s feasible long-term based on his history of losing special interests when he admits that this subject is exactly that (His work history is mixed—had a good record of job retention in his 20s but more recent jobs were much rockier).

The question I would have is whether this person can engage in goal-oriented behavior when the goal operates outside of sphere of their personal interests. It sounds like that may be a source of occupational (broadly defined) impairment for this individual, which is what is leading to your hesitancy to support/fund this person.

Another way of thinking about it might be: what would you need to see from this person to feel confident supporting them? If I were to hazard a guess, it would be some level of task persistence on tasks outside of their personal interests. If true, than is there a way that the intervention you are holding can assist the patient in achieving their aim? If not, then what would?

 

[Psychai]

It sounds like this patient has his mind made up and isn't seeking therapy to help decide whether or not to pursue a PhD in his special interest. I would share your concerns, but it's rarely helpful to try and convince someone that their long term life goals are unhelpful or unrealistic if they've made up their mind (although that may not be the case if your setting serves some sort of gatekeeping role for funding, etc). From my limited experience in a VA SMI setting, we would generally try to go along with life/vocational goals whether or not the treatment team thought they were feasible and would work on the next skill that would help get a patient to their goal. And if the goal is unrealistic, that will eventually become clear, and they've gained skills approaching an area of interest/functioning either way. Many of those skills can still be applied to a more realistic goal, the patient keeps their sense of agency, and you can assist with managing disappointment and redirecting efforts where relevant.

I think that if his therapy goal is to prepare for a PhD program in his special interest, there are many tangible skills he can be practicing (interview skills, interpersonal skills, managing distress, self-advocacy skills, financial literacy especially relating to student loans) that will be helpful in many settings. And there are probably some creative behavioral experiments you could assign for homework that could help him weigh the pros and cons of this course of action along with a motivational interviewing approach in session (ex. Spend 30 hours in the next week researching a topic of interest in this field and write a 10 page paper; if successful, next week do the same thing with your previous special interest). Ultimately the worst case scenario is likely that he doesn't finish the program, has student loan debt, loses this as a special interest, and is only marginally more qualified for some job adjacent to this area. Since that outcome does seem possible, it may be worth working on some contingency planning for how he would know if the situation were heading that direction, when to cut his losses to minimize damage, and how he would be able to cope with that outcome.

 

[PsyDr]

1) this is an interesting intersection between the symptoms of a diagnosis and bad choices. Some of the vacillation in interests is slightly different from the standard ASD dx criteria, especially in the "fixated" portion. It's interesting to determine whether this individual's choices are motivated by his developmental disorder, or the choices are motivated poor judgement. It's not like he'd be the first 30 year old dude who wanted to change his career because.... 30 year old dude.

2) I wonder if the change in interests is unrelated to ASD. The "typical" interest component with ASD is more of a fixated interest. Is it possible that this variation in interests is more characterological than part of his ASD? No idea if that's the case.

3) Basic MI, what are the motivations, what are the alternatives, etc.

4) I wonder if challenging him, or encouraging him on this plan will only serve to make him more focused on that plan. Sometimes it helps to explore what the fantasy would look like in real life, and what the fantasy would produce (e.g., middle age dude wanting to pursue a 20 Hooters waitress. Exploring that might let him see that Brittanii will want to party until 4am, which is incompatible with that business meeting at 8am).

5) I wonder if you’re getting too involved in this individual. We treat the disorder. Outside of that, patients are free to make bad, or even incomprehensible, choices.

 

[Ollie123]

Haven't encountered this exact situation, but in similar ones I've usually fallen back to being generally supportive/encouraging, but also emphasizing a realistic perspective and need for contingency planning.

"It's great that you finally have an idea what you would like to pursue! It sounds like your interests have shifted significantly in the past though and finding academic jobs can be really hard these days - especially in the humanities! Let's talk about ways you can move forward, but also make sure we really think this through and have some backup plans in place in case 'life happens'".

That's as a therapist where I need to walk the line between rapport, want to capitalize on motivation/behavioral activation to some extent (I'm assuming given the history you mention and comorbid diagnoses), etc. while at the same time not supporting people in potentially making profoundly stupid life-ruining decisions just because "Psychologists should be supportive". I don't have the exact context here in mind (he's asking you all to....fund....his pursuit of this?) so that may well alter the best approach. Hell to the F no I do not think funding his degree is a wise use of financial resources.

 

[Sanman]

He’s already done the BA part (finished recently after a long interruption) and applied to PhD programs, so he’s academically qualified. He’s coming to us because he wants us to support/fund it as a means to enter academia as a profession, but I’m not sure it’s feasible long-term based on his history of losing special interests when he admits that this subject is exactly that (His work history is mixed—had a good record of job retention in his 20s but more recent jobs were much rockier).

To clarify, what exactly is your role here?

 

[futureapppsy2]

Thanks for all the input; our broad role in this setting is in two parts--a) evaluating vocational readiness (e.g.,, are they stable enough for work and/or school?), counseling the patient to help them decide on a vocational goal, and working with them to build skills for success in that goal (e.g., EF skills, health maintenance/treatment compliance, self-advocacy) and b) deciding whether or not the specific vocational goal that the patient wants is feasible given their disabilities/impairments and knowledge, skills, and abilities or could be made feasible with interventions. If we deem it feasible, we can fund the associated training/education. We get cases that are easy "yes's" (e.g., someone with well-controlled depression and PTSD who wants to become an administrative assistant or IT person) and easy "no's" (e.g., someone with on meds for psychosis wanting to become a commercial pilot), but this case is murkier, because there's a behavioral history that suggests it isn't likely to work out long-term but no barrier that's a concrete "this won't work" at the moment. (And yes, it would be much easier if I didn't have the decision-making role here).

 

[futureapppsy2]

Haven't encountered this exact situation, but in similar ones I've usually fallen back to being generally supportive/encouraging, but also emphasizing a realistic perspective and need for contingency planning.

"It's great that you finally have an idea what you would like to pursue! It sounds like your interests have shifted significantly in the past though and finding academic jobs can be really hard these days - especially in the humanities! Let's talk about ways you can move forward, but also make sure we really think this through and have some backup plans in place in case 'life happens'".

That's as a therapist where I need to walk the line between rapport, want to capitalize on motivation/behavioral activation to some extent (I'm assuming given the history you mention and comorbid diagnoses), etc. while at the same time not supporting people in potentially making profoundly stupid life-ruining decisions just because "Psychologists should be supportive". I don't have the exact context here in mind (he's asking you all to....fund....his pursuit of this?) so that may well alter the best approach. Hell to the F no I do not think funding his degree is a wise use of financial resources.

This is more or less what I end up doing with patients with somewhat inconsistent focuses in general, btw--asking them to prepare a written plan of how they will ensure they'll maintain motivation/effort and what they can do if they lose interest in the program partway through (concrete strategies for maintaining effort, help-seeking, transferrable skills, exit points, etc). Then we can talk through it, and see if they're still interested after having to really concretely think through what the program will entail and what it might look like with and without their current (and, in this case, somewhat obsessive) interest. (I also find that it helps to have patients write this stuff out, as those who have only a fleeting interest often don't complete that step, and that provides good grounds for redirect). I think it'll be helpful here for sure.

 

[Psychai]

Thanks for all the input; our broad role in this setting is in two parts--a) evaluating vocational readiness (e.g.,, are they stable enough for work and/or school?), counseling the patient to help them decide on a vocational goal, and working with them to build skills for success in that goal (e.g., EF skills, health maintenance/treatment compliance, self-advocacy) and b) deciding whether or not the specific vocational goal that the patient wants is feasible given their disabilities/impairments and knowledge, skills, and abilities or could be made feasible with interventions. If we deem it feasible, we can fund the associated training/education. We get cases that are easy "yes's" (e.g., someone with well-controlled depression and PTSD who wants to become an administrative assistant or IT person) and easy "no's" (e.g., someone with on meds for psychosis wanting to become a commercial pilot), but this case is murkier, because there's a behavioral history that suggests it isn't likely to work out long-term but no barrier that's a concrete "this won't work" at the moment. (And yes, it would be much easier if I didn't have the decision-making role here).

That sounds like an interesting setting! I'm curious what your usual benchmarks are for feasibility outside of the clear cases. In most cases if someone has the higher education prerequisites for an educational goal would you consider it feasible even if it's ambitious? And if someone didn't have autism and their general interests changed frequently would that feel like a similar level of risk as in this case? On some level it seems like a relatively common situation that people pick jobs based on their interests and may find them less fun in their free time as a result (ex. cosmetology, video game design) but that often leads to keeping the job and losing the hobby. Does previous job and education history suggest that once a role is less novel he is likely to prematurely quit?

And as far as the goals or constraints of the setting, how big of an issue is it if a patient terminates an education plan or training program? If the main risk here is the opportunity cost of the patient not getting assistance with a more realistic goal, it seems like the risk of green-lighting a potentially feasible plan is relatively low. On the other hand, if this is a new, grant-funded program that needs to point to many clear successes to retain funding that may be a different situation.

 

[singasongofjoy]

I would make sure this person is aware of how much time / how many components of "working in academia" are not special interests (not to mention the competition for most jobs in academia). typing in "professor" on O*net is a good place to start.

As an example of the info you can find there, here's a link to the "details" tab for "psychology teachers, postsecondary." The "work activities" and "work contexts" sections might be of the most interest. 25-1066.00 - Psychology Teachers, Postsecondary

 

[futureapppsy2]

I would make sure this person is aware of how much time / how many components of "working in academia" are not special interests (not to mention the competition for most jobs in academia). typing in "professor" on O*net is a good place to start.

As an example of the info you can find there, here's a link to the "details" tab for "psychology teachers, postsecondary." The "work activities" and "work contexts" sections might be of the most interest. 25-1066.00 - Psychology Teachers, Postsecondary

Definitely have that conversation with my patients interested in academia, especially coming from almost a decade as faculty myself. I have to say, I thought the pay, inconsistency, and workload of adjuncting would be more of deterrent than it is.