Treating Children with Autistic Spectrum Disorder

A psychoanalytic and developmental approach

Tami Pollak

• Publisher: Routledge
• Year: 2017
• eBook ISBN: 9781351389976
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Treating Children with Autistic Spectrum Disorder: A Psychoanalytic and Developmental Approach outlines a unique model, the product of over twenty years of experience in working with children with this diagnosis within "Shaked" - a multi-professional educational-therapeutic day-car unit in Israel.

This book provides a comprehensive overview of this model and the psychoanalytic-developmental perspective underpinning it, which weaves together the various professional views into a single fabric integrating a therapeutic network which encompasses each and every aspect of the child's development. Drawing on psychoanalytic and developmental psychology, each chapters is devoted to the daily problems that arise when working with ASD children, such as weaning and toilet training, as well as the effects of ASD on wider family functioning, all in the context of administering treatment to young children in day-care and other non-residential settings.

Treating Children with Autistic Spectrum Disorder offers an essential, practical guide which will be an asset to any clinician working with young children on the autistic spectrum, as well as the parents and siblings of these children.

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Chapter 1
Theoretical background

The experience of the autistic child and the transition towards a post-autistic organization

Tami Pollak

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This opening chapter will serve as a sort of antechamber accommodating the reader as we draw a primary map of autistic space, which will be explored in greater depth throughout the following chapters. I shall outline the basic coordinates orienting psychoanalytic-developmental thinking about autism, relating to central theoretical and clinical dilemmas.

The initial conception of autism as a distinct pathology merited its differentiation from other pathologies by the assumption that the difficulty is derived from the child’s external environment. The child’s strange behavior was understood as a particularly massive display of familiar defense mechanisms vis-à-vis a cold and lethal maternal environment (Bettelheim, 1967). The developmental prism had made it possible for us to step out of this judgmental mire, by assuming that the difficulty lies in the child himself and that autism manifested a halt at a particular stage of universal human development, one which Mahler called ‘normal infantile autism’ (Mahler, Pine, and Bergman, 1975). Both conceptualizations pointed to an extreme manifestation of familiar mechanisms, rather than a unique psychic organization.

Although these two initial positions are no longer accepted today, when autistic organization is construed according to its own distinct theoretical prism, their traces are still common in our countertransference. Even today, it is quite surprising to discover the extent of the unconscious difficulty to leave behind this premature splitting, which constantly raises its head, alongside the decisive conscious negation of both approaches. Even today, it is hard to withstand the temptation to believe that the child’s difficulty is merely a product of damaged parenting or, alternately, that as time goes by, ‘the obstruction will relieve itself’ and the child will resume his normal development. It might be dangerous to sweep such nonintegrated thinking under the rug, since its very existence obliges us to keep minding our responses. These outdated approaches are not secluded in some historical domain, but are rather right here with us, and we must turn our gaze to face them in order to diminish their influence.

How, then, are we to extricate ourselves from the binary division between inside and outside, child and environment? Even Tustin, one of the pillars of the psycho-dynamic approach to autism, unburdened herself of Mahlerian dogma only late in life, after decades of work. Infant observation, as well as some help from Ann Alvarez, had finally led Tustin to acknowledge a third path – the one which guides our work in the kindergartens. Tustin encouraged us not to conceive of autism as a reaction, an arrest, a regression or a disruption of some particular function. In her final paper, she referred to autism as a unique congenital structure, dictating an obstruction of the developmental potential for separateness (Tustin, 1981). In her understanding, we are dealing with a baby which exhibits an extreme predisposition for sensual-fusion, a baby whose acknowledgement of bodily separateness is always traumatically premature. As a defence against this traumatic separateness, the tendency for self-oriented sensuality develops excessively, eclipsing normal infantile sensuality, which is capable of acknowledging the dynamic relationship between self-originating and external stimuli. This brings about the distortion which replaces dependency with detachment and openness with seclusion, inducing disruption at every subsequent developmental junction. This tragic distortion hinders the convergence of the various developmental functions into a unified structure – the self – which enables both subjectivity and communication.

This split-off constellation constitutes a primary and crude level of organization (Klein, 1952), in terms of both internal organization and the evolution of thinking. Dividing the focal point of difficulty between inside and outside, the rigid and dichotomous etiological split I have presented is, in itself, highly characteristic of autistic organizations. It is unsurprising, therefore, that it should prove so difficult to dispose of when thinking of autism. The complexity of autism gives rise to a tendency to entertain fragmented notions of it. Each perspective excludes all others and fosters a type of therapy which fails to correspond to other kinds of treatment. Some view autism as a pathology in terms of defensive organization, stemming from a massive disruption of sensory regulation. Some view it as a reaction to ‘bad’ chemical agents, such as those found in vaccines or various food ingredients. Others indicate that the root of the problem is a cognitive difficulty in integrating different perspectives (Lantz, 2002). Others emphasize the communicative aspect, the capacity for play, acute behavioral disorders, difficulties in attaining a personality structure and so on and so forth. This abundance creates an imaginary reality, in which these various theoretical and practical perspectives exclude each other.

Although autism has been studied from multiple angles for the past several decades, we still do not fully understand the cause of this phenomenon. Nevertheless, we are indeed capable of describing it and conceptualizing its particular inherent difficulties, in hopes of achieving a more effective therapeutic response. Our work in the kindergartens embodies the constant effort to avoid a fragmentary ‘either/or’ position in favor of a more inclusive holding, containing within our minds the profound interrelation of the various functional aspects accompanying the course of development. Focusing exclusively on any isolated professional perspective undermines the ability to provide a ‘good-enough’ response to the developmental needs of the child. Faced with the danger of fragmentation, our work in the kindergartens seeks to address the child’s developmental needs by means of a comprehensive approach, which links these various aspects together. This position is elaborated in the following chapter, which outlines the depth-structure of the therapeutic response offered in the kindergartens. I now wish to present a view which broadens the scope of understanding, as far as our limitations allow.

In order to discuss the link Tustin made between autism, the difficulty in bearing separation and the non-functional use of the bodily-sensual foundation, I will begin with an example of the simultaneous maturation of motion-sensation-affect-cognition-relation and separation in normal development. Imagine a baby crawling up to the living-room table and trying to pull herself up to a standing position. Although her motivation for exploring the space around her is at its peak and despite various motoric, cognitive and communication skills, which have been providing her with ‘I can’ experiences, this time, she did not plan her movement adequately and bumped her head. Her mother responded by making a face, tapping herself lightly on her head and saying ‘ach’ (the Hebrew expression for ‘ouch’). The expression ‘ach’ thus serves as a warning code, shared by the heedlessly explorative baby and her attentive parents, indicating a manoeuvre that may end in pain. Several weeks later, when she was brought to the window to wave goodbye to her father, this baby tapped herself on the head and said ‘ach’. The mother made a sad face, saying: ‘ach, aba halach’ (Hebrew: ‘ouch … daddy went away’). She used this same gesture to help her baby link the familiar sensation of physical pain with emotional meaning, encompassing representation, relatedness and separateness. Some months later, during the similar goodbye ritual, the baby tapped herself on the head, saying ‘lach’ (a short version of ‘halach’ – ‘went away’). ‘Ach’ has become ‘halach’ and by now the baby is capable of linking physical space and the pain of separateness in a way which maintains continuity – relating to both sound and word. Soon enough, the baby learned the word ‘went away’ (‘halach’). At first, she used it to describe any kind of motion in space – for example, when her pacifier fell down, she exclaimed: ‘went away’. Later on, this expression became specifically associated with voluntary movement. In this manner, spontaneous bodily and emotional experiences within relatedness facilitate the birth of words, which, in turn, resonate within a space spanning interpersonal meaning and subjective creativity.

The psychic motion between the benign and painful aspects of separateness is thus made possible by the simultaneous maturation of these various functions. In ASD children, studies have shown gaps of varying degrees between functions that are still attainable in development and those that have been frozen in time. In addition, they exhibited an active attack on the congenital tendency to integrate the various functions in a way that is conducive to the creation of a personality structure. Therefore, we must look for ways of understanding and working with the disruptions stemming from this kind of grossly discontinuous development.

In the world of psychodynamic psychotherapy, the object-relations school, concerned with the most primary organizations of human experience, is the central psychoanalytic approach preoccupied with the study of autism – and one of the dominant sources influencing our work. Those treating autistic children are exposed to the tangibility of the archaic psyche in a way which surpasses treatment of any other pathology. This exposure enables us to perform a unique clinical investigation into the subject’s origins and the initial emergence of psychic functions. For these reasons, the study of autism appeals even to those who are not involved in treating autistic children and has become a cardinal element of the broader discourse regarding primary psychic states.

According to the meta-theoretical mythology of object-relations, found in the writings of Gaddinni (1992) or Tustin (1972, 1981), for example, the subject begins to form in the homogenous mother-infant space, in which separateness, form, structure and time do not yet exist. This hypothesis is not some peculiar psycho-analytic concoction; religion, myth, and philosophy suggest similar existential origins. Let us take, for example, the French philosopher Emmanuel Levinas, whose thinking matured during the same years as that of Tustin and Gaddinni, just ‘across the channel’. Levinas presupposes a state, which precedes the birth of the subject, a state of affairs he calls the ‘there is’ (‘il-y-a’). He claims that in order to approach this state we must divest any subjectivity, identity, and unity from the subject, as we traditionally conceive of it, thus approaching an anonymous and a-personal existence, sheer ‘being’ (Levinas, 1978, 53–62). This sheer being has no ‘I’ and no objects, but it still resounds, according to Levinas, with a ‘rumbling silence’, as that emitted by an empty seashell (1985, 48). This is the paradox of the presence of absence. Rings a bell? I suppose it does: Tustin herself had used the image of the empty seashell to describe her encounter with autism.

How, then, does the subject emerge from this unsettling rumbling of undisturbed silence? For Levinas, the primal rupture in the ‘there is’ occurs through an act of finding a place, made possible by the deviation from the inertia of an infinite continuum. From the perspective of object-relations, we might say that this primary ‘placement’ can only occur in the mother’s lap, as the holding it entails is a precondition for the more mature face-to-face encounter.

I believe that, as therapists in our day and age, after having weaned ourselves from the habits of the split perspective, we may gain access to a field of thought whose core is a paradoxical organization: the encounter with autism is inhuman, unbearable and deeply unsettling as well as highly relevant to any human subject. Perhaps for the observer (unlike the child, who is unfamiliar with the oscillation of paradox), autistic rawness is the most archaic root of the ‘uncanny’, which, as Freud (1919) conceived of it, is always an existential paradox. In the spirit of this paradox, it is important to stress that accepting the notion of an impersonal infrastructure preceding the subject as one of the roots of its existence is in no contradiction with the teachings of Trevarthen (1977), Beebe, Jaffe and Lachmann (1993, 1994, 1997), Stern (1985) and others – who elaborated on what any observant person knows: that the human baby is active and relating and thereby also communicative and inter-subjective from the moment it is born. In the paradoxical scheme I am proposing, the link between the personal and the a-personal binds together two elements that both exclude and create one another. In autism, the roughness of impersonal materiality is exposed as the lack of motion toward the personal and the subjective, bringing us in contact with a ‘being’, which the psyche experiences as intolerable. Autistic psychic space is often depicted as dead, hollow, two-dimensional, void of meaning and so forth, and the encounter with it is often dubbed deadening, numbing, draining, as a kind of black hole which bars all resonance. I think that anyone willing to step into the Styx, that mythological river joining and separating the living and the dead, to suspend their soul in autistic space, will find in it something of the wonder of creation, something that cannot be felt in any other encounter. For me, at least, this serves as one reason for my years-long addiction to autism.

This primary, homogenous space, bereft of separateness, form, structure and time, has been described by Tustin in aquatic terms. Following in her footsteps, we may argue that water and liquidity, arising as a countertransference image, are derived from an identification with the actual watery sensations characteristic of the infantile environment – the amniotic fluid, urine, milk, tears, and others. We may also claim that alongside such bodily concreteness, which is essential for thinking about these layers of experience, liquidity is also a rather astute metaphor for describing ‘oneness’ – at the resolution of our experience of liquid flow, water is a unified, contiguous, and unstructured substance: we have no way of telling one drop from another, the original from the newly introduced – much like Levinas’s notion of origin. In this state of uninhibited admixture, we cannot apply the distinctions and links characteristic of psychic functioning. Autistic children in this state wander around in space, hovering indistinctly from object to object, moving between activities without any change in affect; they are utterly unaware of the importance of the Other and they run like water from any attempt to hold their attention. Without the experience of dependency, one cannot feel the sorrow of lack; in this context, we can fathom Meltzer’s claim that autism is a state void of all anxiety. While it may be free of anxiety for them, it provokes much anxiety and agitation in those around them. Those Others shoulder alone the responsibility for any ‘twoness’, for acts of creation designed to ‘divide the waters’. Eventually, however, we cannot help but come up against the anxiety of separateness. This maneuver both overwhelms the autistic child with primal anxieties and ignites the processes of mentalization, resulting in a huge challenge for him and those around him.

Another important fact suggested by the metaphor of a ‘liquid’ state is the realization that in order to make use of a liquid, we must resort to an external factor that would determine its accumulation. It makes no difference if this accumulation occurs naturally (in a riverbed or a gully), voluntarily by using our body (in our mouth or our hands) or culturally, in artificial containers (such as drainage basins, vases, glasses, etc.). Nature, our body and our culture all constitute frameworks for a transition – from formlessness to form – and are all equally necessary for the creation and aggregation of the subject. The utter dependency of the liquid on a form-giving object is associatively conducive to the depiction of the absolute dependency of the baby on maternal holding, and that of the autistic child, who regardless of age still manifests a liquid organization, on the psychic mechanisms of those caring for him.

In order to step into this experience of complete dependency and contemplate its relation to autism, I wish to invite the reader to an excursion at sea, to embrace a hypothetical situation that I have devised, inspired by one of my favorite artists, Jenny Holzer:

At a random spot on the beach, a post is fixed in the sand, on top of it is a metal box, holding a spotlight which emits a beam of light. The spotlight is constantly projecting its light and when the sea is calm, it is aimed just over the horizon, so that the beam of light and the surface of the sea form two parallel lines that will never meet. Most visits to the beach reveal nothing – the spotlight projecting into infinity and the indifferent sea are completely alien to each other. Why then bother observing these apathetic neighbors? Why have I dragged you all the way to the beach? Because things, nevertheless, change when these basic conditions are radically altered – when the wind is blowing and the sea becomes wavy, the rising waves create a surface which encounters the beam of light, which now has something to refract on. This refraction causes a sentence to emerge. A corny lover’s line such as ‘I love you, Johnny’. Now, the sentence that only existed in potential is revealed, existing in a shared space: alienation and indifference are transformed into a gesture of love and communication. And then… . As the wind subsides, it all vanishes once more. And one can remain standing there…. Just waiting for the wind …

I think that the frustration over a state of affairs in which no object will appear and no space will open is all too familiar to those spending time with an autistic child. Why did I invite him into my clinic? How can this be called therapy? The most potent experience is that of helplessness – we are powerless to cause the sea to swell with waves! But the extent of our helplessness equals that of our sense of wonder, as I mentioned before, in the moment of revelation. The elusive eco-system I have depicted is both private, intimate and essentially unique – miraculously addressi...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Contributors
• Preface
• Constitutional History
• 1 Theoretical background: the experience of the autistic child and the transition towards a post-autistic organization
• 2 The structure of the multi-professional therapeutic response for preschool-age children with autism
• 3 ‘I’m not moving, don’t you move!’ Treating a child with an organic disorder and autistic defenses – an integrative case study
• 4 In the beginning was the Word? Some theoretical and technical considerations in working with ASD children – a case discussion
• 5 The body-schema and the development of the self
• 6 Thoughts on diaper weaning and its contribution to the development of the self in ASD children
• 7 The autistic constitution and its impact on the disruption of parental functioning
• 8 In spite of and because of words
• 9 The consulting room – the structure, texture and beauty of the object as a path for the development of primal psycho-physical space
• 10 Dimensions of (non-)space and the autistic state
• 11 The multi-aged child
• Bibliography
• Index