Autism and Personality

Findings from the Tavistock Autism Workshop

Anne Alvarez, Susan Reid, Anne Alvarez, Susan Reid

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134686490
• Edition: 1
• Topic: Psychologie
• Subtopic: Histoire et théorie en psychologie

Taking a psychoanalytic and developmental approach, Autism and Personality outlines in considerable detail the new developments in therapeutic techniques used by the Tavistock Autism Team and Workshop to treat autistic children. It also underlines the importance of support for parents and siblings, who are all too often ignored under considerable stress. The book presents fresh ideas about the importance of personality for the developmental course of the condition, and the implications for psychotherapeutic technique. Using case vignettes to illustrate the theoretical ideas emerging from the Workshop, coupled with case studies which highlight the patient's changing contact with the therapist, it gives a fascinating picture of the individuality of each child and of the sensitivity and skill required for each treatment. Accessible to professionals and also to parents, Autism and Personality is a valuable insight into the nature and course of this condition and its treatment.

1 Introduction

Autism, personality and the family

Anne Alvarez and Susan Reid

This is not just a book about autism. It is a book about children and young people with autism and the ways in which their individual and unique personalities may interact with autistic symptomatology. The Oxford English Dictionary (1971) defines personality as ‘the quality, character or fact of being a person as distinct from a thing’, or ‘that quality or principle which makes a being personal’. It also defines it as ‘that quality or assemblage of qualities which makes a person what he is, as distinct from other persons’. There is something so striking, so mysterious and disturbing about the condition of autism, especially the reduction of personhood in the sufferer, that it seems inevitable that researchers and clinicians tended to concentrate in the early decades on the features which autistic people had in common, rather than on those which distinguished them. Here we emphasise that every person with autism is different, and that there is a close and dense interweaving between the symptoms and the personal motivation of the children, adolescents and young adults described in these pages. We also intend to illustrate the way in which each patient described has, interwoven with their autism, an intact, non-autistic part of their personality. This non-autistic part may use, misuse and exploit the autistic symptoms, or it may oppose them and make efforts to reduce their influence. As patients begin to notice and to enjoy the feeling of coming out of the ‘deep freeze’ of autism, they may begin to value states of greater emotional depth and even to struggle to preserve and maintain them.

The autistic condition

Autism is a severe disorder which affects young children massively in their mental and emotional development. Children with autism do not engage in normal emotional relationships with people. They do not seek communication with people in the ordinary way. They do not play normally, and frequently carry out strange repetitive rituals and behaviours (Kanner 1943). These features are often accompanied by severe developmental delay in all areas of the child’s functioning. They seem to lack a sense of a world in which there are people with minds who could be both interesting and interested in them. This is now known to be essential for the development of a human mind, where thoughts may occur, experiences be remembered, links made and imaginative life develop (Stern 1985). The majority of us have a capacity to judge mental states and some intuition about the feelings and motivation of others – in an ordinary sense to be ‘mind-readers’. Normally developing children naturally acquire a set of increasingly sophisticated social and communication skills. They can imagine, pretend, interpret and recognise the feelings of others and detect intentions that are not communicated by speech alone. They come to know, and be interested in, when another person says one thing but means something else. They come to understand humour and irony. Their acts acquire intentionality. They know that if they do A, then B is likely to follow: experiences, experiments, repeated over time form a vast storehouse, a repository to be drawn on. From this bank of experiences ordinary children recognise what is similar and what is different about whatever situation they are in – they become emotionally literate.

Children with autism, in contrast, do not have rich inner worlds in which experiences and phantasies can be stored ready for some lively interaction with others and where new thoughts can be stimulated by new experiences. An inner world implies a three-dimensional space, including perspective, vertices, and differentiated contents. This is what the person with autism lacks for most of the time. However, close observation shows that, although it is not fully available or accessible, an inner world is rarely entirely absent. It is as if the three-dimensional space were fragile and unstable: a small breeze might cause it to collapse in on itself like a pack of cards.

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’ (Leslie 1987; Frith 1989). Because of our study of very early infantile development and its stress on the social/emotional foundations of cognition – that is, on the precursors of ‘the precursors of theory of mind’ (Baron-Cohen 1992) – we tend to concur with writers like Hobson (1993) and Trevarthen et al. (1996) who view autism as a disorder of intersubjectivity, as a lack of a sense of other persons. We formulate it as an impairment of the normal sense of emotionally based curiosity about, and desire for, interpersonal relationships.

It is important to remember that autism is a condition which arises in early childhood: however fixed and limited its symptomatology may seem, it is exposed to developmental forces which compound the picture and complicate the course of the illness in myriad ways. In recent years many children have been referred to our service with a current diagnosis of mild Asperger’s Syndrome: we learn that some of these children were diagnosed as severely autistic at the age of 2 or 3. Sometimes the parents tell us of their own heroic efforts to draw the child back into contact; in other cases we hear of improvements after the child went to a particular language unit or nursery school. Our own clinical findings of improved outcome after treatment lead us to be unsurprised by these changes and partial recoveries, but to be nonetheless even more interested in learning about the conditions for amelioration or deterioration. The child and adolescent psychotherapist’s long and intensive contact with these patients may have much to offer to the subject of autism, not only for purposes of intervention and treatment, but also because such contact provides a rich source of data for the study of the nature of the condition itself.

In Chapter 2 on assessment, and in Chapter 5 on disorder and deviance, we consider the factors in the persistence of the condition of autism, but our focus everywhere in the book is equally on its mutability and its responsivity. Although people with autism have much in common, we are particularly interested in the differences between them as people, and in the fact that the autistic state of mind fluctuates from moment to moment within any individual with autism. This factor makes it extremely confusing for parents and professionals in their attempts to make contact.

The impact of autism on the family

For parents, sisters and brothers, the burden of living with an apparently uninterested and unreachable child may produce a state of permanent hurt, shock and grief: outside the home, the families of these normal-looking but severely handicapped and strangely behaved children are often exposed to public and humiliating embarrassments. Their lives may become severely limited, with consequent stress on the parents’ marriage and effects on the mental health of everyone.

Unfortunately for people with autism and their distressed families, there has been great controversy about the cause of their mysterious condition. In the past, some professionals took extreme points of view, leading them to split into two separate and opposing camps. In the cognitivist camp, many asserted that the evidence for genetic or other organic causation (implying an inborn deficit) led inevitably to a pessimistic view of the modifiability of the condition. Some psychodynamicist writers in the USA saw autism as a defensive avoidance of ‘refrigator’ mothers, and this led to guilt for parents and a psychotherapy which concentrated on the children’s ‘defences’ and ‘fears’ and neglected their genuine disorder and real developmental delays. In both camps, issues of cause were unfortunately confused with issues of treatment. Nowadays, both groups have moved towards a greater recognition of multiple causation and some recognition that we need to bring together different areas of expertise in order to provide a concerted attack on the problem (Bailey et al. 1996). Reid discusses a possible aetiological factor in a particular sub-group of children with autism in Chapter 7. She discusses the difference between the effect of actual external trauma on an ordinarily sensitive very young infant, and the – apparently traumatising – effect of quite ordinary life experiences on particularly hyper-sensitive infants. Other possible integrations arise from the fact that many cognitivists are now more interested in intervention (Howlin 1997: 95). Many psychoanalytic therapists are more aware of the need to take account of the deficits in cognition, the hypersensitivities and the difficulties in what psychoanalysts call ‘introjection’, the taking in and processing of experience (Tustin 1981a). Alvarez, in Chapter 5, describes her patient Samuel’s difficulty in trying to ‘take in’ the fact of two identical objects. Pundick, in Chapter 12, describes her patient Carmen clutching desperately at her therapist, and Reid, in Chapter 8, speaks of Catherine ‘sucking’ words in and trying to sort out the difference between foreground and background. Therapists have also had to adapt their technique to take account of the considerable developmental delay present in autism (see Chapter 4).

The Tavistock approach

In any psychoanalytic psychotherapy, therapist and patient embark together on a journey and, although neither can know quite where the journey will lead them, some maps are usually provided by a substantial body of psychonanalytic theory and practice lore. Therapists working with autistic patients have learned that special problems are involved if we are to reach a child who does not understand that he or she is a person and has little idea that their therapist is a human being. In the Tavistock Autism Workshop we have developed techniques of psychotherapy which attempt to take account of the developmental delay, disorder and defensive or deviant structures in patients’ functioning. We describe these methods via narrative descriptions of the work with individual patients in the hope of elucidating the unique problems and personality of each one. The struggle to reach severely ill patients has caused us to question and reflect upon every aspect of our psychotherapeutic method and, indeed, upon the nature of human engagement.

The patients

The range of children referred to the Tavistock has led us to think in terms of sub-groups, each of which requires subtle but essential adaptation in the therapist’s technique. Some have very strong, even bullish personalities which demand a firm, not too accommodating response if they are to notice our presence. Others impress us with their delicacy, even fragility, and extreme sensitivity and caution are required if they are to begin to tolerate engagement. Tustin (1972) distinguished the encapsulated shell-type child from the more passive amoeboid type. Wing and Attwood (1987) have delineated a differentiation from the point of view of psychiatric description. They have also pointed out that people with autism are similar to other psychiatric patients in refusing to stay put in the diagnostic categories assigned to them. We, too, in our clinical practice, are aware of the need to be open to the possibility, even probability, that as treatment proceeds, the bullish children may reveal vulnerability behind their thick-skinned façades. The hypersensitive children, on the other hand, may well reveal reserves of stubborn determination initially masked by their delicate presentations. Recognition of the existence of different sub-types within the autistic condition, together with increased attention to the defining features of the patient’s personality, has allowed us to achieve greater precision in our psychotherapeutic technique. This has led to improved outcomes.

The patients described in this book range in age from two years to young adulthood, and vary in the severity of their condition. The majority received diagnoses of autism from centres other than the Tavistock, prior to referral to us. The treatment offered was from once to five-times weekly psychotherapy, with the majority seen three times a week. The cases illustrate variations in the responsiveness of each child and the variable levels of improvement. Because tragic limitations are imposed on the lives of families, parents are offered help both individually (see Chapter 3) and in parents’ groups. We present accounts here both of young or responsive children whom we have helped to get back onto the path of normal development ( and 11), and also of those who are at the severely ill end of the spectrum either in terms of degree of autism (Chapter 5) or of chronicity (Chapters 7, 13 and 15). In the more severe cases, although it may not be possible to effect a major reversal of the process, nevertheless we usually expect to have a significant impact on the quality of the autistic person’s life, and on that of the family. Work with very severely autistic patients, furthermore, both informs and illuminates the work with the less severely autistic people. Chronicity brings problems in its own right, and this has important implications for early detection and treatment. The study of the more chronic conditions also throws much light on the course of the condition and, by definition, therefore, on its nature.

Therapeutic technique

Dawson and Lewy (1989: xvii) write:

Although it is possible that we may never ‘cure’ autism in the sense of eliminating the primary cause of the disorder, a realistic and worthy goal of applied autism research is to devise therapies that ameliorate the secondary negative consequences of the primary abnormalities.

Although we do not suggest that the lack of emotional relatedness to others is the primary cause of the disorder, we do think it is the core and primary symptom, and it is towards that area of the patient’s condition that we direct our treatment. Early detection of the precursors, at eighteen months, is essential (e.g. Baron-Cohen et al. 1992), but it is our view that a study of the precursors of the precursors, – that is, of the infant’s state of mind and of social relatedness in the early weeks and months of post-natal life – will confirm the psychoanalytic and infant developmental view, and that of some autism researchers (Hobson 1993) that, although impairment of social relatedness may not be the core cause, it is the core symptom.

The psychotherapy is informed by three major elements in a child and adolescent psychotherapist’s training. All three – psychoanalysis, infant observation and infant development research – involve a study of the nature of interpersonal relations, both in the external and internal worlds. These are applied to the very close observation of the individuality of people with autism.

Psychoanalytic features of the approach

Psychoanalytic treatment involves three major features:

(a) the regularity and consistency of the setting;

(b) the use of the transference; and

(c) the use of the counter-transference.

Developmental researchers and infant observers agree that cognitive and communicative ‘skills’ arise through emotional relationships with caregivers. Like Hobson (1993) and Trevarthen et al. (1996) we think that the social impairment is the core symptom, and this is why we work via the relationship between patient and therapist.

The setting

The regularity of the appointments, together with the consistency of the location of the sessions, is important for the recovery of all patients in psychoanalytic forms of treatment, but especially so for autistic patients where a safe, predictable setting is often the first thing which impinges on and attracts them. Like plants which need ‘heeling in’, they may begin to put down roots and to grow a mind. Parents and teachers must cope with these children for several hours at a time, and every type of contact has its particular stresses and strains. Therapists’ particular training involves the toleration and exploration of intense feelings – of anxiety, of despair or of boredom. Their role is to stay with these feelings and not to avoid them. The fifty-minute limit provides a structure which enables therapists to help patients to manage the unfolding of intense and primitive feelings. These feelings may be particularly powerful as they begin to emerge from autistic states of mind, when their intolerance of ordinary human frailty and imperfection becomes more exposed.

The transference

Therapists use the transference – the patient’s attitude and relationship to the therapist – as the lens through which to view the patient’s world of relationships to others. The patient’s changing relationship to the therapist – and, if all goes well, their developing attachment to the therapist – is not seen as a substitute for their relationship to their parents. Rather, it is a way-station on the route back to the important relationships with the real mother and father. Improvements in patients’ capacity for emotional communication can make them more accessible to parents’ caregiving. It is our experience that it is the emotionality in the contact which promotes change in social relatedness, communication and thoughtfulness. Interestingly, in this context Howlin (1997: 91) has pointed out that training in social skills for people with autism offers some help but does not generalise greatly. It is our view that we are changing deeper structures in the mind, and it is this which supports generalisation.

The counter-transference

The counter-transference is understood as the response evoked in the psychoanalyst by the patient’s feelings (see Chapters 2 and 4). Yet the problem with most autistic patients is that of a lack of feeling, a lack of communicative expressed emotion. In general, we can all ‘mind-read’ others’ intentions and states of mind. But when attempting to ascertain intentionality and meaning in the actions of a person with autism we often get a sense of meaninglessness. This experience is disconcerting, alienating, puzzling. It lacks the ordinary ingredients of mutual curiosity and interest. The autistic child either lacks the capacity for, or is not interested...