Asperger's Children

Psychodynamics, Aetiology, Diagnosis, and Treatment

Robin Holloway

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367103774
• eBook ISBN: 9780429910999
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The DSM-5 (2013) classifies all autism-related disorders, including Asperger's, under the heading "autism spectrum disorder." This book argues that this lumping together is unhelpful for clinicians. Instead, finer diagnostic distinctions are helpful to clinicians who treat children with Asperger's. This book spells out in detail the psychodynamics the author has repeatedly uncovered in Asperger's children, adolescents, and adults, and explores the central factors in the aetiology of Asperger's Disorder. There is a section suggesting how Asperger's can be adequately diagnosed from "the outside" (using external descriptive features) and more importantly from "the inside" (based on internal psychodynamic processes). Finally, there is a section outlining psychodynamic treatment approaches to Asperger's children, based on their psychodynamics and on which type of Asperger's is present. The book includes numerous case illustrations to help the reader appreciate the central psychodynamics that are regularly observed in Asperger's children, namely splitting of the self into victim and bully aspects, and projective identification into remote objects.

CHAPTER ONE
Introduction

I now provide an outline of the contents of this book, how it has been organised, and sketch in some of the main conclusions I have formed. The aim is to give the reader a "pre-conception" or a road map of where things are going, to make reading and digestion of the content a bit easier.

There are four main parts which comprise this book, these four parts being: Part I: The psychodynamics of Asperger’s children; Part II: Theorising about the aetiology of Asperger’s; Part III: The diagnosis of Asperger’s children, and Part IV: Treatment approaches to Asperger’s children.

Part I: The psychodynamics of Asperger’s children is the “clinical heart” of this book. This part contains ten chapters. Chapters Two through to Eight all begin with the heading “Some clinical dialogues with Asperger’s patients”. These seven chapters recount clinical dialogues with eight different Asperger’s patients whom I had the privilege to treat over the years. These patients are arranged in order of increasing age, beginning with Peter and Joe (Chapter Two) who were both nine years old when I saw them, and concluding with Anthony (Chapter Eight) who was thirty-one years old. By accident, they also repeat the approximate order in which I met these children. Each chapter contains one or more selected fragments of clinical dialogue which I had with each of my patients. They were recorded shortly after the sessions in which they occurred, and are accurate in their gist even if not accurate word for word. The selection of these dialogues was made in order to illustrate the conclusions I describe in Chapter Nine (“The psychodynamics of Asperger’s children”). What I conclude is that Asperger’s children regularly (and likely invariably) employ two main defensive operations: splitting of the self into victim and bully aspects, and projective identification into remote objects. These two processes are described in detail in Chapter Nine, and are hopefully persuasively illustrated in the clinical dialogues reported in Chapters Two through Eight. In Chapter Nine, I also discuss the possible role trauma may play in the production of Asperger’s disorder in children.

The longest of the “clinical dialogues” occurs in Chapter Three, which relates parts of conversations I had with twelve-year-old Matt. This is the longest of the “clinical dialogues” chapters, and has a slightly different structure from all the others. All the other “clinical dialogues” are derived from single sessions. The clinical dialogue with Matt in Chapter Three is presented as a single dialogue, but is a compendium of selected dialogues from a number of sessions which occurred over a period of months. Matt was an extremely articulate preadolescent who was able to describe in intricate detail the ongoing and shifting relationships between the two aspects of his split self, which he referred to as the “antelope” aspect (referring to the victim part of the split) and the “tiger” aspect (which was the bully part of the split). My hope is that assembling these various selections into one continuous dialogue will give the reader a more complete and accurate conception of how the parts of the split in Matt’s self interacted with each other.

Chapter Ten, entitled “The anxieties and defences of Asperger’s children,” is designed to be a continuation of and further elaboration on the content of Chapter Nine. As to the anxieties experienced by Asperger’s children, I suggest there are two main kinds, which I refer to as “existential anxieties” and “relational anxieties”. The former kind of anxieties, the “existential anxieties”, involve what I call “separateness anxiety”, meaning the perception of being separated from another experienced as part of the self, and thus as amounting to a rupture of adhesive identification. The “relational anxieties” involve separation anxiety, understood in the traditional psychoanalytic fashion.

The defences of Asperger’s children are described as operating on three levels. The first level involves the “cornerstone defences” of Asperger’s children as outlined in Chapter Nine, that is, splitting of the self into bully and victim aspects, and projective identification into remote objects. The second level involves a series of defences which are typical for Asperger’s children, but are not “mandatory” in the way the cornerstone defences seem to be. The third level consists of defences typically understood as employed by autistic children. These are the “autosensuous defences” which include the use of autistic objects and autistic shapes.

The final chapter of Part I is Chapter Eleven, entitled “Defences in Asperger’s children continued—Should we call it splitting or dissociation?” This chapter is conceived of as a direct continuation of Chapter Ten with specific reference to the defences used by Asperger’s children. The issue is to distinguish splitting from dissociation. The problem is that splitting is a kind of dissociation and dissociation is a kind of splitting, creating a potential difficulty in adequately distinguishing between the two. At a fundamental level, both splitting and dissociation involve separating two aspects which actually belong together, and keeping these two aspects in a continuing state of separation. Without entering too deeply into theoretical issues around distinguishing these two types of defences, I try to examine how splitting/dissociative defences are used by Asperger’s children in order to suggest whether splitting or dissociation is the most likely process being used in cases of Asperger’s.

Turning to Part II: Theorising about the aetiology of Asperger’s— this part includes two chapters. These are Chapter Twelve: Towards an understanding of the aetiology of Asperger’s disorder, and Chapter Thirteen: The sensory vulnerability of Asperger’s children. As the title of this part suggests, it is the most theoretical part of the four parts. The attempt is to reconstruct what might happen in the mother–infant dyad when the infant is born with the potential for Asperger’s. I suggest that in general, the mother of the Asperger’s infant attempts strenuously to make an emotional connection with him and to understand him. At times she is able to do so. I suggest this results in the infantile perception of “the connected mother”, which is accompanied by a sense of “the protected self”. At other times, she cannot do so. Then the result is an infantile perception of “the disconnected mother”, in tandem with a sense of “the overwhelmed and vulnerable self”. In Winnicott’s language, there is variability in the adequacy of maternal holding. In Bion’s language, there is variability in the mother’s reverie and alpha-function, and thus variability in the adequacy of the infant’s experience of containment.

Chapter Thirteen examines the issue of sensory vulnerability in the infant, and how this kind of vulnerability might contribute to difficulties in the mother–infant dyad.

Part III: The diagnosis of Asperger’s children includes one chapter, Chapter Fourteen: The differential diagnosis of Asperger’s children. I explain my differentiation of three types of Asperger’s a bit more fully just below, because these types are mentioned in the earlier chapters involving “clinical dialogues” with Asperger’s children (chapters Two– Eight). It will thus be helpful to the reader to have some preview of what I am referring to.

Chapter Fourteen approaches the diagnosis of Asperger’s from the outside, based on external descriptive features, and from the inside, based on internal psychodynamic processes. I review strong criticisms of the diagnosis of Asperger’s disorder as it was set out in DSM-IV, concluding that this diagnosis was doomed because it was utterly inade quate from the start. I also criticise the inadequate, unhelpful, and totally lame manner in which the diagnosis of “autism spectrum disorder” (ASD) is handled in the DSM-5, where every aspect of autism is lumped together into one undifferentiated gelatinous glob, Asperger’s is ignored, and the clinician who actually treats these children is not helped at all. However, there is also a constructive aspect as well as a critical one. I suggest in detail how the diagnosis of Asperger’s (from the outside and based on external descriptive features) could have been salvaged instead of being jettisoned because the DSM-IV attempt at diagnosis was so completely inadequate.

I then consider diagnosis from the inside as based on internal psychodynamic processes. This is what should have happened in the Psychodynamic Diagnostic Manual (2006), but for unfathomable reasons did not. Instead, there was in the PDM an ignominious regression into purely biological psychiatry, which ignored years of psychoanalytic investigation. The reasons for such a demoralising and humiliating capitulation on the part of a manual which is typically extremely helpful is utterly incomprehensible. One can only hope that the next iteration, the PDM-2, will rectify this embarrassing lapse.

I attempt some degree of rectification (in a manner that will hopefully benefit clinicians who actually treat children who are “on the spectrum”) by outlining three types of Asperger’s that may require different treatment approaches, and then trying to suggest in a preliminary way how the three types may be handled differently in treatment.

The three types of Asperger’s children that I have so far been able to discern are: the inhibited/avoidant type who are object-shunning, the inhibited but object-seeking and needy type, and the uninhibited and aggressive type who are object-rejecting. In this context, “object” refers to external objects and not to internal objects. Note that these categories are rough and broad in nature, and will not capture the details of many individuals with Asperger’s. They are meant only to provide some kind of initial orientation that is helpful to the clinician. This categorisation is based mainly on which aspect of the split self tends to predominate in the child. For the inhibited/avoidant type who are object-shunning, it is the victim aspect of the split self that predominates. The focal anxiety tends to be what I call “existential” in nature, that is, the child questions whether they even exist for others in any significant way. For the inhibited but object-seeking and needy type, there is an oscillation which is sometimes very rapid between victim and bully aspects of the split self. Anxieties also tend to involve both existential and relational kinds, so that their questions tend to involve both whether they really exist for others, and if they do, whether others can value them. Finally, for the uninhibited and aggressive type who are object-rejecting, it is the bully aspect of the split self which usually predominates. Their focal anxieties tend to be relational, but with a strong paranoid-schizoid colouration, so that they wonder why others are out to hurt, denigrate or belittle them. Details of the three types are outlined in Chapter Fourteen. This initial orientation should help the reader understand the references to the three types in some of the earlier chapters.

Finally, Part IV: Treatment approaches to Asperger’s children, embraces two chapters, Chapter Fifteen: Thoughts about the treatment of Asperger’s children, and Chapter Sixteen: Treatment of Asperger’s children—The Toronto experiment. Chapter Fifteen begins with a review of some of the treatment suggestions in the non-psychoanalytic literature. I then outline two psychoanalytic views. One view outlines the range of psychotherapy and the different types of psychotherapy available to the clinician. This derives from the work of Paulina Kernberg and her colleagues. The other is Anne Alvarez’s (2012) description of three levels of psychotherapeutic intervention. I try to suggest how the work of Kernberg can be integrated with that of Alvarez by suggesting how Anne’s levels of psychotherapeutic intervention can be mapped onto Paulina’s types of psychotherapy. I then attempt to apply this to the treatment of Asperger’s children, using my treatment experiences with three Asperger’s children to suggest what might be the most useful kind of treatment approach to these children.

Chapter Sixteen: Treatment of Asperger’s children—The Toronto experiment is a continuation of Chapter Fifteen, focussing on a specific case, the case of a young adolescent I call Jack and his family. In Chapter Sixteen, I outline how I have attempted to realise in practice the ideal treatment approach outlined in Chapter Fourteen. This involves a collaborative effort involving three psychoanalytically trained therapists. I try to describe the benefits that seem to derive from this approach, and I also try to employ candour and self-revelation (not without risking a degree of embarrassment) in outlining difficulties (“bumps in the road”) that this experiment has involved.

This present chapter is intended to be no more than an initial road map and orientation to the rest of the book. It will hopefully provide the reader with an idea of the whole forest we are about to enter. If it does so, it may then make focussing on some of the individual trees easier and more informative. We are shortly to meet Peter and Joe (Chapter Two) and begin the “clinical dialogues” of chapters Two to Eight. I can only hope this road map is useful, and that your trip through the forest proves to be worthwhile.

Part I
The Psychodynamics of Asperger's Children

CHAPTER TWO
Some clinical dialogues with Asperger's patients—Peter and Joe, age nine

We begin our reflections on Asperger’s disorder by considering some dialogues between a number of Asperger’s patients, ranging in age from nine to thirty-one years, and myself as their therapist. All of these patients are males, reflecting the predominance of males with Asperger’s. I present my patients in order of age from youngest to oldest. We begin with Peter and Joe in this chapter, both of whom were nine years of age when I saw them. I saw Matt (Chapter Three) for a number of years, but the dialogue I present is primarily from when he was twelve years of age. Thomas (Chapter Four) was also twelve years of age when I saw him briefly. The remaining four patients whose dialogues I present were also seen over a number of years. Thanos (Chapter Five) was fourteen years of age at the time of the dialogue I will present, and is still in treatment. Dan (Chapter Six) was seventeen years old, Alan (Chapter Seven) was nineteen years old (and still in treatment), and Anthony (Chapter Eight) was thirty-one years of age.

I attempt to tell you enough about each patient so that you can develop an initial sense of the person before you hear our dialogues. These dialogues were transcribed immediately after the session with the patient and are likely t...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHOR
• CHAPTER ONE Introduction
• PART I: THE PSYCHODYNAMICS OF ASPERGER'S CHILDREN
• PART II: THEORISING ABOUT THE AETIOLOGY OF ASPERGER'S
• PART III: THE DIAGNOSIS OF ASPERGER'S CHILDREN
• PART IV: TREATMENT APPROACHES TO ASPERGER'S CHILDREN
• REFERENCES
• INDEX