Invisible Boundaries

Psychosis and Autism in Children and Adolescents

Didier Houzel, Maria Rhode, Didier Houzel, Maria Rhode

• Publisher: Routledge
• Year: 2018
• Topic: Psychology
• eBook ISBN:
  9780429915239
• Subtopic: Autism Spectrum Disorders
• Index: Psychology

This volume is an outcome of the European Federation for Psychoanalytic Psychotherapy conference on psychotic and autistic conditions in childhood and adolescence, encouraging the cross-fertilization of psychoanalytic practice and theory across the international boundaries in Europe.

CHAPTER ONE

Autism and psychosis¹

Anne Alvarez

Philip Roth wrote recently that politics and literature are not only in an inverse relation to each other, they are in an antagonistic relationship:

To politics, literature is decadent, soft, irrelevant, boring, wrong-headed, dull, something that makes no sense and really oughtn’t to be. Why? because the particularizing impulse is literature. How can you be an artist and renounce the nuance? But how can you be a politican and allow the nuance? As an artist the nuance is your task. Your task is not to simplify. The task remains to impart the nuance, to elucidate the complication, to imply the contradiction. [Roth, 1998, p. 223]

For politician and artist, one could read researcher and clinician, or diagnostician and therapist. Yet the relationship need not be antagonistic. I will be saying a lot about nuances and complexities in children with autism and psychosis, but I shall also make a tiny attempt to bring some order to bear on the clinical issues and on the nature of these mysterious conditions of childhood.

I will begin with a discussion of autism and end with some links with borderline psychosis and personality disorder.

Autism

The question of the primary impairment in autism

There is much controversy about how best to describe autism, about where to locate the core damage, and about the nature of the core impairment. Some authors prefer a cognitive explanation, i.e., that people with autism are born without the capacity eventually to form an adequate “theory of mind” (Frith, 1989; Leslie, 1987). Clinical findings from psychotherapy, together with the study of very early infantile development, which has supported psychoanalytic ideas regarding the social/emotional foundations of cognition— that is, the precursors of “the precursors of theory of mind” (Baron Cohen et al., 1996)—has led us at the Tavistock Autism Workshop (Alvarez & Reid, 1999) to concur with writers like Hobson (1993) and Trevarthen and colleagues (1996) who view autism as a disorder of intersubjectivity, as a lack of a sense of other persons. Hobson (ibid., p. 15) points out [and much developmental research (Stern, 1985) and naturalistic infant observation (Miller, Rustin, Rustin, & Shuttleworth, 1989; Reid, 1997) support his assertion] that the concept of persons is more fundamental than either the concept of bodies or the concept of minds. Susan Reid and I have formulated the autistic impairment as an impairment of the normal sense of mutual, emotionally-based curiosity about, and desire for, interpersonal relationships.

We do not suggest that such impairment is the primary cause of the disorder. The complexities of multiple causation, and the interaction between genetic, pre-natal, and post-natal environmental factors must await further research. We do suggest, however, that such impairment in relatedness needs to be addressed as the core and primary impairment. Such primary impairment (with its related deficits and disorders) needs to be distinguished from secondary disorders, tertiary deviance, and a fourth factor that accompanies all three, that of the individual child’s personality and motivations. All four factors need our attention during assessment and treatment: their accurate description is relevant, by the way, to the important question of subgroups of autism (Wing & Attwood, 1987; Wing & Gould, 1979). The passive, indifferent, “undrawn” child who has never quite awakened to the interestingness of people and of the world may require a somewhat more active technique from us than does the more aloof and avoidant, “withdrawn”, “shell-type” child. The former may need help to become a person, the latter to reveal his hidden personhood. We may need to draw very close to the former, and be careful to respect distances with the latter. Of course, children do not stay put in neat diagnostic categories, and the same child may need a different approach at different moments. Yet, it is worth noting the differences between these varying states of mind, and the patients themselves seem to appreciate our sensitivity to such nuances.

Work with families, schools and the network

The trauma of having one’s child receive a diagnosis of autism, and the degree of confusion and rejection experienced by those who live with such a child, have been well documented by Susan Reid (1999) and Trudy Klauber (1999) in Autism and Personality. They note, however, that it is not only the anguish and disappointment that needs processing: there is also the further problem of the ways in which families may have come to adapt to their child’s condition. They may have begun to give up expecting ordinary parental rewards; they may have settled for a lesser form of relatedness. A pull on the wrist by the child will get the required banana, the grunt tends to get the door opened. Parents may need much help not only to mourn the lost healthy child, but also to rediscover what health remains, and to hold out for it against their child’s bad habits of mind. They may need, like therapists and teachers, to learn to read very faint signals of health where larger signs are absent, or to begin to set more ordinary boundaries and to make more ordinary demands for civilized behaviour. I am not going into detail about this work with parents and the network, but wish to say that the work with the individual child, except under very rare conditions, cannot proceed without it. A few examples will emerge when I get to the clinical material.

The work with both child and parents needs to be twin-pronged: it addresses both the autistic symptomatology and the intact or spared “non-autistic” part of the child, however develop-mentally delayed this may be (see Bion, 1957 on the distinction between psychotic and non-psychotic parts of the personality). These two aspects of the patient’s functioning have two widely differing trajectories or courses of development and both need careful study, and treatment where possible. For all its apparent stasis, the autistic condition is much less static and more mutable than it sometimes appears. While a micro-second’s glance by a child at a new toy in the room may be followed by an instantaneous return to old rituals, the quality of the child’s glance may nevertheless offer a clue, a faint signal that can be amplified and built upon tactfully.

Bion did not discuss the question of the age of the healthy part, but I would stress that it is vital that therapists assess, and, indeed, carers be alert to, the precise developmental level at which this apparently more normal part of the self may be operating. The child’s chronological age may be five or ten years, but the non-autistic part may, depending on how long the child has had autism, be very much younger. The “infantile” part of the personality described by Klein and others may be two years, three months, or even three weeks of age. When the child finally becomes interested in toys, or games, say, these may need to be more suitable for a baby of ten months than a child of five years. This information can be usefully exchanged between members of the treatment team and teachers or carers, any one of whom may be the first to note a possible new development or problem. The difficult issue of when a child will not manage a new activity, when he cannot, and when he feels he cannot, is another issue that requires good collaboration, where we all need help from each other to better understand these children. We do not consider our approach as a rival to educational or behavioural interventions, only as a complement. A more manageable or more educated child may produce a somewhat happier child and family, but a more interested, psychologically engaged child may bring even more pleasure to himself and others.

I now want to return to the individual treatment, the first premise of which is a psychoanalytic object-relations one. That is, we do not study only the patient’s self, but also the state of his internal objects and object relations. These internal figures may need treatment just as much as the self does. Several authors have commented that both in developmental research and in psychoanalysis, the old split between emotion and cognition is breaking down. Urwin (1987) pointed out that we need no longer see emotion as slowing down or speeding up cognition, but as entering into the structure of cognition itself. The interestingness of the world is not appreciated on a purely cognitive level and psychoanalysis has much to offer on this subject. The second premise of the therapy is that a disorder of the capacity for social interaction may benefit from a treatment that functions via the process of social interaction itself. The third one asserts, as I have said, that the treatment must take account of the developmental level at which the child is functioning at any given moment.

I now want to comment briefly on treatment of deficit or delay, and then spend somewhat more time on issues of disorder and deviance.

Addressing the deficit: therapeutic implications of deficit in the internal object

Waking the child to mindfulness and amplifying preconceptions

This aspect of the work is more relevant to the undrawn, not the withdrawn, child. The child may not yet be interested in us, but he may begin by becoming interested in our interest in him. This particular subgroup of autistic children seems to be rather like Wing’s passive indifferent group, and appear to be lost, rather than hiding. Unlike the Rainman, whose brother tells him he knows he’s in there, these patients seem to have forgotten, or perhaps have never quite known that they are in there and others are out there. In this state of mind, (because the categories do shift at moments), a more active technique of “reclamation”, of calling the child into eye contact, say, may be helpful, (so long as it is tactful and distances are respected if the child becomes avoidant in the next moment).

One three-year-old girl, Angela, had a repetitive preoccupation with doors, and spent the first two assessment sessions staring through the door of a dolls’ house. My colleague and I speculated, together with her equally mystified mother, whether it was the tunnel effect that attracted her; was it the symmetry—there was a window opposite—or was it the inside of the house that fascinated her? Nothing seemed to fit. On impulse, in the third session I got down on my knees and peeked back at her through the back window of the house. The effect was electric: Angela was delighted, and celebrated by plunging her head smiling in her mother’s lap. I do not think that Angela was looking for a human face at that moment. Yet she knew it when she saw it. We underlined Angela’s wish to share her pleasure with her mother. There are important issues here: first, it is important, during an assessment, to discover the child’s capacity to respond; at the same time, it is equally important to help parents to learn how to engage the child better, without making the parents feel accused of having given up, or of being responsible for the child’s original autistic condition. Angela’s needs were not being clearly expressed. In this situation the child and parent can fall or drift further and further apart. If Angela was looking for something, she didn’t quite know or remember what it was. She was in a state of pre-expectation, rather than expectation. Like Klaus and Kennell’s (1982) and Brazelton’s (Brazelton, Koslowski, & Main, 1974) mothers calling their babies into contact, I think for a moment I provided what Bion (1962) called a realization of a preconception, not of a concept. I met a pre-need, not a need. The child needs repair to his ego defects (Sandler & Sandler, 1958)) but also to the defects in his internal objects. Everyone concerned with the child may need to be sensitized to respond to, channel, and amplify signals that are weak, delayed, or highly immature. We may find ourselves responding in a manner similar to the mother of a two-week-old baby, and this may begin the repair of faulty internal objects.

It is not only our social and socializing behaviour that needs to be developmentally informed. Our language too, may need to be simple, not to demand too much two-tracked complicated thinking arising from “why-because” interpretations, i.e., “you are angry because . . .” may be too much for a confused, disorientated or unorientated child. Simply getting to know that he is angry today, and finding out what that feels like, may be a vital first step that should not be skipped over. At moments, the therapist may even have to use what Trevarthen has called “motherese”, a soft singsong voice—in common parlance, baby talk—to get through to a child who does not listen to ordinary, more adult-or schoolage-appropriate speech.

Play, too, may need to be very simplified. If the child has never played ball, then we may first have to begin with finding out if he has any interest in passing objects from his hand to ours, or even, as with even younger babies, accepting objects from our hand to his. Ball play may be months away if this early stage of turn-taking, and the even earlier stage of proto-conversational turn-taking, has not been reached. At other moments, of course, when the child is more present and aware and his behaviour has more intentionality and motive, more ordinary psychotherapeutic work may take place. I would maintain that the work with these children remains both developmentally and psychoanalytically informed. Getting a balance between, on the one hand, attempts to focus and engage the child, to turn preconceptions into concepts, by being developmentally attuned and therefore more active, and, on the other hand, leaving him space to have his own experience once he is enough in himself to be able to do this, is a perpetually difficult task. It is by no means simply a question of playing with the child.

Some possible primary disorders of arousal and introjection

Samuel, a four-year-old patient of mine, was a very tense boy with severe autism and at first he seemed full of a barely controlled, almost frenzied excitement. He had several relentless and repetitive behaviours, gazing at his claw-like fist, or at running water, or at spinning wheels, or his own reflection in shiny surfaces. Some while into treatment, when he was much calmer and more related, I was astonished to find that, even at his most happy, friendly, cooperative, and less autistic moments, his heart was racing like a terrified wild bird’s. I never learned whether it was racing in the same way when he was off in a corner absorbed in one of his repetitive behaviours and out of emotional and social reach; I certainly got the impression that sometimes these behaviours did serve to calm him; they were a bizarre and dangerously addictive, but nevertheless effective form of self-soothing.

Psychoanalytic clinicians were among the first to comment on the problem of excitement and excitability in children with autism. Tustin (1981b) described the children’s difficulty in “filtering” experience, their states of unbearable ecstasy: she described a child completely overwhelmed by the yellowness of a yellow flower. Meltzer (1976, p. 20) suggested that they were bombarded by stimuli. American researchers have explored what they have called unusual levels of arousal in children with autism (Dawson & Lewy, 1989). This work adds another dimension to the psychology and the psychoanalysis of autism. It reminds us that the positive or negative content of experience is only one aspect; another is its intensity. Many children with autism seem to be as disturbed by positive experiences as by negative. Questions of intensity, overload, over-sensitivity and over-and under-stimulation are very much the subject of study in infant development research and infant observation. They relate to the question of how, or for that matter, whether, experience can be taken in or introjected.

To return to the question of how to understand Samuel’s racing heart, or what Dawson calls “arousal” and its effects, avoidant behaviour and frustration have been shown to be associated with increase in heart rate but, in infancy, the orientating response and attention to the environment are associated with decrease in heart rate (Tronick, 1989). Samuel seemed to want contact with me at such moments—to be orientating towards me and attending to me, not avoiding me—but yet, at the same time, he was very disturbed by it. Dawson and Lewy (1989) stressed the importance of therapies that take into account the question of what is the optimal level of stimulation for a child. Many of these children are thrown into a terribly turbulent universe when they relax their guard. I think this may be more characteristic of what Wing and Attwood (1987) termed the “aloof” subgroup, [or what Tustin (1981b) called the shell-type child] than of the more floppy indifferent child (see previous section and Wing and Attwood, 1987 on the “passive” subgroup).

Disordered arousal and introjection: lowering the intensity

Samuel, like his mother, was very short-sighted, but as he often destroyed his glasses with his ritualistic shaking of them, his mother suggested he leave them with her during the sessions. I was, after all, not teaching him or asking for close work. After about six months’ treatment, Samuel, who had hardly ever stopped to look at anything in the room, finally became interested in a little blue cube-shaped brick. Much work had to be done in helping him to “filter” even an experience as apparently simple and easy as gazing at a brick. Some weeks later, he noted that there was more than one brick, and began to pick up two identical blue ones at a time. He would look at them briefly, as though for a fleeting second he was examining and enjoying their symmetry and the way he could put the two cubes neatly together, and then he would suddenly squash them together and make them explode into the air, as though they had erupted. He would be overcome by the same sort of disturbing excitement whenever he came close and looked into my eyes or at my face. Then he would suddenly dash away, carry out his hand ritual, and lay his face close to the open section of the window. At first, I thought he had returned to the old autistic state of mind, but I began to suspect that he was often still in touch with me at such moments. I came to think that he had simply gone over to the window to “cool down”.

After another six months, he had slowed down somewhat, and co...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication Page
• Contents
• Editors and Contributors
• Series Editors’ Preface
• Introduction
• Chapter One Autism and Psychosis
• Chapter Two Time, Space, and The Mind: Psychotherapy with Children with Autism
• Chapter Three The Symbolic and the Concrete: Psychotic Adolescents in Psychoanalytic Psychotherapy
• Chapter Four Splitting of Psychic Bisexuality in Autistic Children
• Chapter Five Comment on “Splitting of Psychic Bisexuality in Autistic Children”
• Chapter Six Conversation with Geneviève Haag (EFPP Conference, Caen, September 2001)
• Chapter Seven Conversation with Raymond Cahn (EFPP Conference, Caen, September 2001)
• References
• Index