Psychoanalytic Work with Autistic Features in Adults

Clinical Intervention Methods and Technique

Laura Tremelloni

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781138497788
• eBook ISBN: 9781351014571
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Psychoanalytic Work with Autistic Features in Adults deals with the diagnostic and therapeutic difficulties of working with patients with autistic residuals, formed in early life experiences that have remained dormant in the unconscious mind. Laura Tremelloni traces the process of identifying them in adult patients, and stresses the need to develop a treatment plan suitable for this kind of pathology.

This book uses clinical cases to examine the difficulties of work with hard to reach adults with 'gaps' in their sense of Self and symptoms related to primitive experiences of "non-being". Tremelloni presents new, adaptive therapeutic intervention methods for overcoming such obstacles and identifies the personification and permanence of undeveloped parts of the Self, in hard to reach adults who have otherwise developed satisfactorily and would not be diagnosed as autistic. In such cases, the author suggests the need for clinicians to adapt classic psychoanalytic approaches to the alternating levels of development of the separate parts which the Self has broken into.

Psychoanalytic Work with Autistic Features in Adults will help clinicians in psychoanalysis and psychoanalytic psychotherapy to more effectively reach such patients, whilst attempting to address the problematic limitations of therapeutic techniques in very difficult clinical cases.

Part I

Chapter 1

About autism

1.1 Autistic traits and features in adults

Starting from the 1970s, following studies on autism in children, several authors began discussing adult patients with traces of autism (Winnicott, 1960; Rosenfeld, 1979, 1987; Klein, 1980; Tustin, 1986; Ogden, 1989; Mitrani, 1996; Tremelloni, 2005; Barrows, 2008; Civitarese, 2013). These patients are characterized by having a part of the Self that is sufficiently developed to conduct an apparently ‘normal’ social life, while another part of the Self has remained incomplete due to a defective development of the process of symbolization.

In psychoanalytic work, the analyst is faced with patients who are initially considered to be neurotic or borderline. She then realizes that it is impossible to establish any form of real communication with them. This difficulty is due, in part, to a lack of personal meanings in their thoughts, due to a lack of symbolization, and in part to the avoidance of emotional contact, which is a trace of early psychological suffering. The primitive emotional suffering dates back to the foetal period and to the very first years of life. This pain was perceived on a sensory and affective level and recorded in the unconscious mind; it remains unknown. It is part of the non-represented material and is kept in the implicit memory. Mancia (2003) holds that this material kept in the unconscious mind can be traced in the process of psychoanalysis only through the patient’s dreams and transference.

During their early development, these subjects have buried more or less intense or extensive experiences of autistic states, alternated with schizoparanoid mental states. This alternating of mental states comes to light during the course of psychoanalytical work. This primitive pain may also reveal itself in cases of psychosis.

The only possible communication in the analytical relationship can take place in the intuition of the pain and the emotional needs of the patients, which the analyst can perceive through her countertransference and reverie.

In a previous publication (Tremelloni, 2005), I traced the history of the term ‘autism’ used in psychiatry, and I described the autistic residuals as ‘capsules’ or ‘autistic nuclei’. This concept refers to a more or less extended psychic area which contains traces of primitive autistic reactions to extreme childhood anxiety and sensory experiences that have not been processed. These encapsulated parts of the personality can remain hidden under psychosomatic personalities or neurotic, psychotic or borderline psychological organizations.

Identifying this type of pathology is key to ensuring that the psychoanalytical intervention is appropriate for the individual’s degree of development of the Self.

1.2 Searching for non-mentalized experiences

The reflections of this work relate to therapy with adult patients who have developed a partially neurotic, psychotic or borderline psychological structure, which may or may not have already been analysed. As a result of emotionally significant events, these patients experience sudden episodes of terror and show signs of personality disintegration.

As I have already indicated, this occurrence was described and studied by many authors in the second half of the last century. Linking the origins of such symptoms in early life experiences, Bion (1962) speaks of children who have known ‘nameless dread’. Winnicott (1971a) believes the fear of mental breakdown derives from primitive anxieties that re-emerge as a result of the environment’s inability to meet the child’s needs. Tustin (1986) speaks of ‘uncontrollable unnamed terror’, ‘states of non-experience’ and ‘the black hole’. Grotstein (1990a) describes the experience of the ‘black hole’ as a frightening sense of lack of power and ‘non-existence’, or as a centripetal force towards emptiness. He specifies the subject feels that there is no human presence in the space outside the Self, or rather, that there is a malevolent and inhuman absence.

These archaic and sensory-dominated experiences are defined as ‘un-mentalized’ (Mitrani, 2008) because they have occurred prior to the child’s ability to symbolize. In my previous work, I defined these early experiences as ‘autistic-type capsules’, and described how they remain buried in the Self until they are identified and acknowledged later on in life (Tremelloni, 2005).

Given the degree of Ego development that has enabled these patients to reach a satisfactory level of social relations, it is difficult to imagine that these individuals possess a frail and needy Self. This situation confuses the analyst who, caught between the false Self and the true Self, cannot discern a real request for help. Due to their early emotional fragility, the efforts of such people have been directed towards the construction of a solid personality and a robust set of skills.

However, in the early stages of contact, one may notice certain peculiarities in the relational distance, such as the individual’s inability to acknowledge the difference in roles, an excessive familiarity, a lack of discretion or tactlessness. This highlights the fact that there is very little awareness of boundaries and personal space. Moreover, such people manifest a deficit in the process of symbolization and attribution of meaning.

Premature encapsulation contains primitive emotional experiences that have been frozen and buried in the unconscious within rigid structures; they are hidden behind defences that have been erected for psychic survival. Because these individuals do not undergo the process of self-development, they remain static and enclosed in a strong armour that protects from ‘feeling’. In these early experiences, there is a persistent lack of trust regarding stable emotional relationships, but there is also a positive and vital potential.

By paying attention to changes in the transference and countertransference, we can pick up the existence of autistic experiences from subliminal signs, which we perceive in the fluctuating emotional contact. Thus, in an attempt to track these primitive experiences, we can follow different paths, trying to emerge from the confusion brought on by the patient’s intertwined defensive responses.

The pervasive anxiety of these first encounters can be masked by great self-confidence, different degrees of mania and lack of doubt regarding the meanings of the stories these individuals bring to the analyst. One may be surprised by a tendency to deny that there is any anxiety in meeting the analyst: the patient may appear to be festive and jovial as one would be with old friends. Other times, the overbearing part of the personality emerges in an attempt to fill the void left by emotional deprivation.

One may come across delusional ideation or troubling physical symptoms: the focus tends to be on the body as the place of primitive conflicts and confusion between the Self and the other. The concepts of closeness, distance, separation and individuation have not been processed and thus create anxiety.

As communication progresses, the pathological situation becomes more evident; the patient enters a state of acute crisis and experiences a sense of disorientation and confusion about the Self, leading to a more or less explicit request for a fusional relationship with the analyst.

The experience of non-differentiation accompanied by high levels of anxiety confirms the re-emergence of primitive experiences, which may include the lack of corporal boundaries, the terror of falling into a limitless and formless space, and the absence of a relationship with an object able to support and contain the individual.

In such cases, the beginning and the course of the psychoanalytic process are riddled with difficulties in the transference; this signals the re-enactment in the relationship with the analyst of the crippling experiences of loneliness, lack of trust and persecutory fears.

When the moment of crisis seems to be overcome, the analytic relationship becomes once again very difficult, albeit in different ways. This is due to the pathological personality structure. The destructive feelings attached to these autistic experiences cause various defences to be erected and consolidated, confusing the analyst.

These defences vary and can be represented by intellectual constructs in which words are detached from feelings; they are autistic objects not aimed at communication, but rather at exhibition. In the case of a patient of mine, an aspiring writer, my words were scrambled and repeated in literary productions and intellectual formulations: these productions were more akin to imitation than to the internalization that characterizes an evolutionary process. The compositions masked a rejection of real emotional contact with the theft of a few valuable elements from my words.

At other times, what prevails may be excessive projective identification, used to eliminate persecutory anxieties or feelings of anger. Such defences prevent the analyst from seeing the patient’s need for help, and this hinders the analytic work. The need for help is projected onto the other, prompting the mask of altruism, a denial of one’s own aggressive feelings through seductive or falsely generous behaviour.

Another solution the patient uses with regards to the pain of reconsidering the entirety of his or her life story is escaping into mania or humour, transforming painful feelings into excitement or sadistic attacks. Another solution may be an actual escape from analysis through a sudden interruption.

Narcissism is another important obstacle to the development of thought in analysis; it may be so strong that it does not allow one to listen to the other. Other forms of defence may be: the persistence of psychosomatic symptoms and hypochondriac states; an obsessive mode of thought which prevents any transformation; the use of acting-out, especially in the forms of substance abuse or sexual behaviour.

In conclusion, when faced with the difficulties that arise from the inability to work with free associations or attribution of meanings, linking thoughts with discontinuous affective behaviour, countertransference remains the principal therapeutic research tool.

1.3 Non-represented mental states¹

My interest in primitive non-mentalized states initially arose from my clinical work with children with autism, and later with adult patients who, while seeming potentially analysable, manifested specific difficulties in taking up classical analytical work through personal affective communication.

To listen analytically means to continually integrate contents with their temporal and logical connections, and with the feelings aroused in the analyst. All this is also linked to his or her theoretical background. The development of the traditional analytic discourse is hindered by the difficulty in establishing these links, along with a reduced affective relationship and a communicative vacuum. On one hand, the analyst is faced with the patient’s suffering; on the other he or she must deal with the impossibility of establishing a connection between the current anxiety and the story that is being remembered and recounted.

These clinical experiences moved me to search for theoretical explanations. Starting from the work of Alvarez, Bion, Green, Sidney Klein, Ogden, Tustin and Winnicott, several recent studies have broadened my theoretical understanding of these issues in order to come up with some therapeutic changes.²

The representational ability is the result of the psyche’s active primordial work in dealing with internal stimuli (drives) and external stimuli (perceptions). The psyche will gradually organize itself through the establishment of the object relationship, the memory of different emotional experiences, the repetitions or changes of the surrounding environmental events and their interconnections. The ability to represent the absent object will allow the development of thinking (Freud, 1913; O’Shaughnessy, 1964). The non-neurotic patients we are discussing, however, are unable to represent a primary object (Reed, 2009).

The representation of the absent object shows how the ability to think enables the mind to hold onto what is not directly perceived in a given moment in the surrounding space.

Non-represented mental states are a sign of a representational deficit linked to traumatic experiences in a pre-verbal period that have led to autistic or psychotic nuclei. These are evident in states of anguish and emptiness: they are impossible to describe, they can be expressed through action and not through words, they reduce the ability to link thoughts with feelings.

Reed (2006, 2009) reflections are an elaboration of the contributions of Green and Winnicott. Green (1983a, 1986, 1993, 1997, 1998, 2002) initially addressed the issue of non-represented states in his work with adult patients. In his work on the dead mother (1983b), he suggests that in these cases the identification with the mother is a representation of the absence of representation. One can think of it as an empty mirror in which the patient loses his reflection. This unconscious identification that cannot be translated into language remains unrepresented in the unconscious.

For Green, the representation of the primary object takes place only if a vital instinct prevails over the death drive and the withdrawal of object investments. In non-representation, the conflict is to be found between investment and the creative power of love that unites a baby to life on one hand, and the death drive on the other, which leads to a withdrawal of that investment. The latter case has a de-objectifying function (Spitz, 1965; Green, 2002), meaning a disconnection from any search for meaning. When the internal tension provokes a strong dissatisfaction, the defence aroused to quell the tension causes the renunciation of the object, and all is obliterated: this is the vacuum that Green calls negative hallucination. In this vacuum there is no perception of an object or of a perceptible psychic phenomenon; it is the equivalent of a loss of meaning.

Green highlighted the vacuum in these patients’ symbolic representations. If the vacuum holds something that can neither be expressed through words nor even be thought, the transference happens through the object rather than through the use of words. Words are thus used to express instinctual needs and are therefore devoid of specific meaning: they express the need for a transitional object to act as a real object.

From a therapeutic point of view, if the vacuum represents the residue of the solution to past conflicts, the patient looks to the current setting for what was missing in the past: that is, someone to pay attention to him, to listen to him, to take pleasure in being with him, to offer verbal explanations so that he may invest positively in a less disappointing transitional object.

When the patient has to face an unpleasant external reality, he reacts with variab...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright page
• Table of Contents
• Preface: Explorations in terra incognita
• Acknowledgements
• Introduction
• PART I
• PART II
• PART III
• Conclusions
• Index