Contacting the Autistic Child

Five successful early psychoanalytic interventions

Jorge Ahumada, Luisa C. Busch de Ahumada, Jorge L. Ahumada

• Publisher: Routledge
• Year: 2017
• eBook ISBN: 9781315452395
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Amid long-standing controversy on their causes, which most regard as neurological, and despite their increasing social impact, there has been scant progress in the therapy of the autistic spectrum disorders. Currently fashionable attempts at treatment through behavioural-cognitive focal approaches do not seek resolution, only re-education and rehabilitation. Contacting the Autistic Child explores the clinical process in the early psychoanalytic treatment of autistic children. Organised around five detailed clinical case studies, and drawing on the ideas of major clinicians in child analysis such as Tustin, Winnicott and Alvarez, this book sets out a clear programme for working with and understanding autistic children in a psychoanalytic setting, with a particular focus on issues of clinical technique but also conceptual matters.

Working on the notion that autistic disorders come to be – as Winnicott and Tustin saw it – from an early rupture of the affective communication between baby and mother, this book aims at reinstating such communication in the child-analyst interaction. By way of detailed description of what goes on in the analytic link, the authors strive to make the reader share in what goes on in the clinical setting, evincing how, though at times excruciatingly hard on the therapist, resolution is attainable. Once the "primal dialogue" – to use René Spitz's terms – is reinstated in a stable way in session, it flows by itself into the family ambience. The clinical accounts of this book make the argument that psychoanalysis, carried along Tustin's technical lines, and subject to the proviso that treatment starts early, preferably in the first three years of life, is the treatment of choice for autistic spectrum disorders. The strong methodological narrative is important and notable in light of the doubts, criticism and uncertainty that have surrounded the psychoanalytic treatment of autism.

This novel, highly detailed narrative of five successful early treatments aims to help dispel the pessimism pervading the field and help to redress the lives of many more children. Contacting the Autistic Child will appeal to psychoanalysts and psychoanalytic psychotherapists endeavouring to obtain results in a major area lacking resolutive approaches.

Chapter 1
Autism

An historical approach

Leo Kanner was a child psychiatrist, not a psychoanalyst, but the title of his landmark 1943 paper, “Autistic disturbances of affective contact” continues to define the field. He described a unique syndrome starting before age 2, of which the outstanding disorder is

the children’s inability to relate themselves in the ordinary way to people and situations from the beginning of life. Their parents referred to them as having always being “self-sufficient”, “like in a shell”, “happiest when left alone”, “acting as if people weren’t there”, “perfectly oblivious of anything about him”.… There is from the start an extreme autistic aloneness that, whenever possible, disregards, ignores, shuts out anything that comes to the child from the outside.

(Kanner 1943, p. 242)

Of his initial 11 patients three were mute, the others used language peculiarly, mostly as parrot-like repetitions of heard word combinations, unhooked from purposes of personal communication: affirmation, Kanner says, was indicated by the literal repetition of a question. Their performances were as monotonously repetitious as their verbal utterances, and they became greatly disturbed upon the sight of anything broken or incomplete; dealing repetitively with objects – typically, by spinning – provided them a gratifying sense of undisputed power and control. They never looked at anyone’s face. Some had phenomenal memory capacities.

Among Kanner’s many astute observations stands his noting in 1951, having examined 100 cases at Johns Hopkins Hospital, that the autistic child does not differentiate between himself and others or between an “I” and a “you”, and that there is no sympathy, treating the animate, mother included, as inanimate: as is often mentioned they look through you, not at you. Such children, he highlighted, strenuously resist education, which is lived as a dire intrusion.

To Kanner, differing from later authors, in all cases the disturbance was there from birth on. Initially, he said, parents going to the crib to pick up the child notice that there is no anticipatory reaction; later the child does not run to the parent when he comes home and does not respond to verbal address. Soon after, he was able to boast at a panel in the American Academy of Pediatrics that “Certain features are so typical that, when a 4 year old autistic child is brought to the clinic for the first time, my secretary comes in and tells me that there is an autistic child in the waiting room, and she is usually right” (1953, p. 403).

Kanner kept infantile autism conceptually apart from child schizophrenia, though he granted that some children later fell into it; others emerged by themselves from the autistic disconnection, while still others remained in extreme withdrawal. Adults starting as autistic children were, he said, peculiar and withdrawn, but they never had delusions or hallucinations. In the assumption that “these children have come into the world with innate inability to form the usual, biologically provided affective contact with people” (1943, p. 250), just as other children come into it with innate physical or intellectual handicaps such as dyslexia, Kanner held that infantile autism was not influenced by any form of therapy. Independently, Hans Asperger in 1944 had described an akin syndrome, which differed in that language was preserved and children with the syndrome often showed surprising abilities. Coincidentally with Kanner, Asperger considered that the syndrome he described “was of constitutional origin and genetically transmitted” (Firth 1991, p. 13).

For Kanner autism was a varied lot, encompassing typical childhood cases as well as withdrawn but seemingly functioning adults (usually described as schizoid). Such wide panoply in the severity of autism was, however, mostly lost to the public, likely because Margaret Mahler and Bruno Bettelheim, who brought child autism into the psychoanalytic fold, considered autism to be the severest of child psychoses. Bettelheim (1967), in his widely influential book The Empty Fortress, put the clinical lens on the sickest cases, interned for treatment at late age, years after illness started. Indeed, the three patients he detailed – Laurie, Marcia and Joey – were long-standing cases who presented elaborate delusional systems, blurring the limits with childhood schizophrenia. His work took place in an in-patient setting; he privileged residential treatment under psychoanalytic guidance, holding that outpatient treatment works only when the disturbance is relatively mild and the child is still very young (p. 407). Fortunately, by the standards of his three detailed cases, most autistic disturbances, when seen early enough, can aptly be considered “relatively mild”: it is precisely the children being “very young” and their being treated as soon as feasible after going into autistic retraction that brings fully into play psychoanalysis’s therapeutic “window of opportunity”.

Among Bettelheim’s perceptive clinical observations we single out, firstly, that these children have, and impose, an out-of-this-world, mechanical view of their universe; secondly and notably, on the “I”: when asked “do you want milk?” the autistic child replies “you want milk” (meaning “yes, I want milk”). This echolalia serves defensive purposes; in creating a language that fits his emotional experience, the autistic child evades using personal pronouns the more so these refer to himself, avoiding the term “yes” as much as the word “I”. As he magisterially puts it, such language derives from the child’s anxiety about being himself; his depleted selfhood can assert itself only in negation (pp. 424–428). The survival value of such posture, he masterly adds, is that “if ‘I’ do not really exist, then neither can ‘I’ really be destroyed” (p. 429).

As previously said, Kanner was sceptical about treatability. Bettelheim, though, stressed having been able in long-term residential psychotherapeutic treatment at the Orthogenic School in Chicago to reverse autism’s course. Prognosis was better for speaking children than for mute ones: out of his 26 speaking autistic children, improvement in 17 he deemed “good”, being for all purposes “cured” and functioning well in society despite residual quirks (1967, p. 417); several of his inmates went on to complete university studies. He compared his results with those of operant conditioning, which forsakes the child’s need for spontaneity: whereby, he bluntly argued, autistic children “are reduced to the level of Pavlovian dogs” (p. 410). Such polemic, initially raised half a century ago, is alive and well today.

The first autistic child to be psychoanalyzed was Melanie Klein’s patient Dick, in her classic paper “The importance of symbol formation in the development of the ego” (1930), but at that time he was not recognised as autistic. Revisiting Dick’s case, Frances Tustin pointed out that Klein registered substantial differences between her patient Dick and the schizophrenic children she had analysed, noting that such cases are often classified as mental deficiency, that Dick was largely devoid of affects and rarely displayed anxiety and then only in an abnormally small degree, and that “against the diagnosis of dementia praecox is the fact that the essential feature of Dick’s case was an inhibition in development and not a regression” (quoted by Tustin 1986, p. 50, italics in original). She also noted substantial differences from Klein’s usual technique: Klein acknowledged that she did not interpret the material until it has found expression in various representations, but in this case, where the capacity to represent was almost entirely lacking, she was obliged to interpret on the basis of her general knowledge (Tustin 1986, pp. 52–53).

Margaret Mahler (1952, 1958, 1968) pioneered, from the 1950s on, the study and conceptualization of an ‘infantile symbiotic psychosis’ as part of the childhood psychoses, side-by-side with Kanner’s early infantile autism. She considered infantile autism and the “symbiotic infantile psychosis” as two variants of childhood schizophrenia. Mahler drew on Ferenczi (1913) for a notion of a “primary mother-infant symbiotic unit” (1952, p. 288); however, keeping faithful to Freud’s and Hartmann’s conceptions of the initial stages of mind, Mahler postulated a pre-symbiotic, normal autistic phase in the first month of extrauterine life, sustaining that “in the normal autistic phase, the infant is not yet aware of anything beyond his own body, whereas in the symbiotic phase he seems to have become vaguely aware that need satisfaction comes from the outside” (1968, p. 165). The normal autistic phase took place from two or three months on to a symbiotic phase in which the infant behaves and functions as though he and his mother were an omnipotent system, a dual unity (1958, p. 77). To Mahler, as used in this context, the term “symbiosis” is a metaphor not having the connotations of the biological term, which implies a mutually beneficial relationship: as found in the symbiotic child psychoses, it can be described as a “parasitic symbiotic” union (1968, p. 55). The term was chosen to describe the state of indifferentiation, of fusion with the mother, in which the “I” is not yet differentiated from the “not-I”, and in which inside and outside are only gradually coming to be sensed as different; unpleasurable perceptions, external or internal, are projected beyond the common boundary of the symbiotic milieu intérieur, which includes the mothering partner: in this, she says, symbiosis resembles the Freudian notion of the purified pleasure ego (1968, p. 9). Mutual cuing signs the symbiotic phase:

the mother conveys – in innumerable ways – a kind of “mirroring frame of reference” to which the primitive self of the infant automatically adjusts. If the mother’s “primary preoccupation” with her infant – her mirroring function during early infancy – is unpredictable, unstable, anxiety-ridden, or hostile; if her confidence in herself as a mother is shaky, then the individuating child has to do without a reliable frame of reference for checking back, perceptually and emotionally, to the symbiotic partner.… The result will then be a disturbance in the primitive “self feeling” which would derive or originate from a pleasurable and safe state of symbiosis, from which he did not have to hatch prematurely and abruptly. The primary method for identity formation consists of mutual reflection during the symbiotic phase.

(1968, p. 19)

Patients who do not achieve true identificatory and internalization processes fall back to the primary mode, the “mirroring kind of maintenance of identity” (1968, p. 31).

Omnipotent symbiotic dual unity eventually leads to a separation–individuation phase with the advent of autonomous ego functions such as locomotion and the beginnings of language: the peak of the symbiotic phase, the third quarter of the first year, coincides, says Mahler, with the beginning of differentiation of the self from the symbiotic object, and thus marks the onset of the separation–individuation phase (1968, p. 220). The intrapsychic separation–individuation process – the child’s achievement of separate functioning in the presence and emotional availability of the mother – continually confronts the baby with minimal threats of object loss; however, pleasure in separate functioning enables the infant to overcome such separation anxiety, as is entailed by each new step of separate functioning. The negativistic behaviour of the anal phase, in the frame of the toddler’s spurt for individual autonomy, is important for intrapsychic separation and self-boundary formation. This, what Mahler calls the practicing period, culminates around the middle of the second year with the freely walking toddler at the height of his mood of elation, at the peak point of his belief in his own magic omnipotence, in good measure derived from his sense of sharing in his mother’s magical powers (1968, p. 20). Attainment of libidinal object constancy (in Hartmann’s sense) is much more gradual than the achievement of object permanency (in Piaget’s sense). During the second half of the second year of life, says Mahler, the child has become more and more aware of his physical separateness and, along with this awareness, the relative obliviousness to his mother’s presence signing the practicing period wanes, which brings in the rapprochement phase with an increased need, and a wish, for his mother to share with him new acquisitions of skill and experience (1968, pp. 24–25).

As Mahler initially put it, infantile autism regresses to primary narcissism: there seems to be, she said, a primary lack, or a loss, of that primordial differentiation between living and lifeless matter that von Monakow called protodiakrisis, and thus the child’s self, even his bodily self, seems not to be distinguished from the inanimate objects of the environment (1968, p. 79). Symbiotic psychosis implied fixation or regression to a delusional omnipotent symbiotic fusion with the need-satisfying object: such fusion evolved through crises of catastrophic panic reactions, inasmuch as inner and outer reality are fused (1958, p. 78). These symbiotic children rarely show conspicuous disturbance in the first year of life except perhaps disturbances of sleep, and tend to be described by their mothers as crybabies or oversensitive; as soon as ego differentiation and psychosexual development challenge the child with a measure of separation from the mother, which usually happens in the third or fourth year of life or with the advent of the Oedipus complex, the illusion of symbiotic omnipotence is threatened and severe panic reactions occur (1952, p. 292). In the idea that the “phantasy of oneness with the omnipotent mother… coercing her into functioning as an extension of the self” (1958, p. 79) is psychotic despite being part of the healthy baby’s early mindset, she fitted autism proper and symbiotic disturbances into the child psychoses, deeming pathological, overly fusional symbiotic states between baby and mother as the risk factor for symbiotic psychosis.

At first Mahler made a sharp distinction between autistic and symbiotic psychosis syndromes, but years later, after treating nearly 40 cases, she concluded that “there is a broad spectrum of combinations of autistic and symbiotic features within the infantile psychosis syndrome” (1968, p. 77): placing each case within this spectrum rests on whether the autistic or the symbiotic defences are paramount. She also came to avow that the intra-psychic situation in the psychotic child “does not involve a regression to any known phase of development” (1968, p. 55). The autistic child’s most conspicuous symptom is that “The mother as representative of the outside world does not seem to be perceived at all by the child” (p. 64). She added that the autistic defense is “primarily a response to the fear of human contact, an armor plating against such contact”, which results in a shutting out of the actual human object in order to effect a delusional denial of the existence of the human object world and therefore of the danger of annihilation while the self becomes deanimated (“devitalised”), a psychotic mechanism that has no parallel in any phase of normal development (1968, p. 79). The symbiotic defensive organization is conceived of as primarily a response to separation panic, that she calls “panic” advisedly because the extent of traumatic anxiety, which includes a fear of re-engulfment by the symbiotic object, cannot be considered a part of the ordinary experience of normal infancy. Fear of reengulfment is conceived as a dread of dissolution of the self (loss of boundaries) into an aggressively invested dual unity that the child cannot magically control (p. 80–81). But, while time and again she described autistic dynamics as psychotic, in a late statement she opened the way to a wider picture: “Milder than psychotic disturbances, I believe, occur in children who, though they have passed through a separation–individuation process, have shown ominous deviations from the orderly progression of the subphases” (1974, p. 102). In such manner, going beyond her initial notion that infantile autism and symbiotic disturbances were variants of childhood schizophrenia, she joins Kanner’s idea of a panoply in the severity of autistic dynamics. On all these points we coincide.

Mahler’s psychoanalytically inspired treatment scheme was built on a “tripartite therapeutic design” (1961, p. 348), which included baby, mother and therapist, a set-up where the therapist served as the catalyst, the transfer agent and the buffer between the child and mother; she thus pioneered parent–child therapies. Her aim was to reestablish a “corrective symbiotic experience” between the baby and the mother as primal object. She was not so optimistic about results, avowing that treatment must extend over many years of the child’s life and that “even with cautious, prolonged, and consistent therapy the prognosis for arresting the psychotic process and consolidating the ego is only moderately favorable” (1968, p. 169).

As his scant references to it, late in his work, are fully set in the context of the child psychoses (1965, p. 153, 1967b, p. 221, 1968, p. 198, 1974, p. 90), it might be thought that Donald Winnicott is not part of the history of autism, but despite his lack of acknowledgment of autism as a nosological entity distinct from infantile schizophrenia, his conceptual contribution is crucial. His statement that

The autistic child who has traveled almost all the way to mental defect is not suffering any longer; invulnerability has almost been reached. Suffering belongs to the parents. The organization towards invulnerability has been successful, and it is this that shows clinically along with regressive features that are not in fact essential to the picture.

(1968, p. 198)

concerns a limit-case, ironclad isolation in shell-type encapsulated autism. Based on this fissure-less idea of autistic invulnerability, he was unremittingly pessimistic about treatment: “therapeutic work with autistic children is maximally exacting, and constantly makes the worker feel: is this worthwhile? There is but slight possibility of a ‘cure’ – only amelioration of the condition and a great increase in the child’s personal experience of suffering” (1967b, p. 221). Thereupon autism was not a focus for Winnicott, but his notion of psychotic depression was a main stepping stone for Tustin’s developments, as was his model of primal mind – a model fusional to a much greater extent than is usually acknowledged – that Tustin in good measure owes to him. Winnicott’s overall concepts of going-on-being, mirroring, transitionality, impingement and play-as-such (distinctly from Klein’s masterly technical use of play technique in session), topics on which little can be found in Klein’s work, find ready place in describing how healthy development proceeds and how the autistic disconnection is overcome. We agree with Winnicott in that therapeutic work with autistic children is maximally exacting, but we trust that the clinical material here presented backs the idea that half a century later we need not subscribe to his therapeutic pessimism.

Let us now address the Kleinian approach furthered by Rodrigué, Bick and Meltzer. Despite titling his paper “The analysis of a three-year-old mute schizophrenic”, Emilio Rodrigué in 1955 held that his quite detailed, if interrupted, case, treated for seven months along Kleinian technica...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Preface
• Foreword
• Introduction: the expanding frontiers of autistic spectrum disorders
• 1 Autism: an historical approach
• 2 Contacting a 19-month-old mute autistic girl: Lila
• 3 Treating encapsulated autism soon after trauma: Axel
• 4 From mimesis to agency: clinical steps in Sophia’s work of psychic two-ness
• 5 Autistic mimesis in the Age of Media: Juan, a screen-bred animal-child
• 6 Clinical notes on a case of transvestism in an autistic child: Jaime
• 7 Conceptual remarks on early mind
• 8 A roaming view of the Autistoid Age
• Addendum 1 Bion’s theory of thinking and autistic-mimetic dynamics: a dialogue with Antonino Ferro
• Addendum 2 On Tustin’s revised edition, a response to Angela Joyce, and an excursus on Ogden’s autistic-contiguous position
• References
• Index