Autistic States in Children

Frances Tustin

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781317835752
• Edition: 2
• Topic: Psicología
• Subtopic: Psicoterapia

Frances Tustin's classic text Autistic States in Children (1981) put forward convincing clinical evidence that some forms of childhood autism are psychogenic and respond to methods of treatment very different from the behavioural techniques often adopted without success. Her pioneering work with such children has gained ground since the book was first published and she herself has revised her understanding of the aetiology of psychogenic autism. This revised edition of the book incorporates her new thinking based on recent infant observational studies and her own clinical experience.

Part I
Childhood psychosis

Childhood psychosis is a state in which the child is massively out of touch with a reality that is shared by other children of the same age. In terms of this definition childhood autism is a psychotic condition.

In this book autistic syndromes are the main focus of my attention, but for purposes of differentiation and comparison another group of psychotic children in whom commonly agreed reality is obscured and evaded in ways other than by autism is discussed and investigated. This group of children is introduced and described in Chapter 3.

Chapter 3
Theoretical aspects of psychogenic childhood psychosis

For organic psychiatrists, the concept of ‘psychogenic’ childhood psychosis is a controversial one, for they see all childhood psychoses as inevitably being the result of organic damage. However, in the psychotic children I have treated by psychotherapy, no brain damage could be detected by the investigative techniques then available, so a psychogenic hypothesis seemed tenable.

In this connection, it is interesting that in a paper concerning an obviously organic type of childhood psychosis, four organicists have written: ‘It is often difficult to distinguish those cases of childhood psychosis which are associated with organic conditions from those that apparently are not’ (Corbett, et al., 1977). This implies that these writers accept that, in some forms of childhood psychosis, an organic etiology is not apparent and a psychogenic one is a possibility. However, even in relation to the children in whom psychogenic factors seem to be the most operative, the cautious child psychotherapist would not rule out the possibility that such children may have minimal neurological impairments or metabolic imbalances which cannot be detected by the physical investigative techniques at present available. This is an area where co-operation with medical colleagues is indispensable. On first sight, it is difficult to know whether the ‘triggers’ for the development of psychosis have been predominantly organic or predominantly psychogenic. To some extent, the degree of organic damage will affect the degree to which psychotherapy can be effective. However, Sandra Stone (see her observations in Chapter 16) has witnessed substantial improvements as the result of psychotherapy with some predominantly organic children. She makes the important point that such children use psychological modes of protection to cope with their organic disabilities, and these can be affected by psychotherapy. However, the possibilities for the outcome of psychotherapy with the predominantly psychogenic children will not be restricted by a ‘ceiling’ set by organic impairments, although if the psychosis has gone on for too long it will have become a way of life that is usually impossible to modify.

Classification

In psychiatric schemes of classification, two main types of childhood psychosis are diagnosed: childhood autism and childhood schizophrenia. Such classification is on the basis of presenting appearance and behavioural characteristics. However, when investigated at the deeper level that is possible in psychotherapeutic treatment, we find that the psychotic children in whom psychogenic factors predominate have been overwhelmed by a tumult of feelings associated with awareness of bodily separateness. Bodily separateness is the prelude to individuation and self-identity. Both types of psychotic child have failed to achieve these developments satisfactorily.

When there has been pathological fusion between mother and baby, such as was discussed in the previous chapter, both mother and baby are in a hypersensitised state when, due to a variety of occurrences, awareness of their bodily separateness is suddenly forced upon them. Their hypersensitised state makes the experience particularly sharp and upsetting. When working with such children it becomes clear that, in a vulnerable state, they had felt pitch-forked into a dangerous outside world. For them, to be psychologically born meant being bombarded by painful sense impressions and flooded by turbulent feelings, for which their psychological-cum-physiological apparatus was not ready and for which, for various reasons that will be discussed later, the parental support and sheltering had not seemed adequate. As will be discussed in a later chapter, their psychological birth had been a psychological catastrophe. Their reaction had been to develop safe havens but, as a recovering previously autistic child expressed it, ‘my sanctuary became my prison’. In this reaction, emotions became an anathema. Endogenous sensations were mustered to keep them out. Thus, both types of psychotic child had dealt with the trauma of bodily separateness (the ‘psychotic depression’, as Winnicott (1958) has called it) by the over-development of auto-sensual protections, but of different kinds. Let me differentiate between them.

• (a) For the childhood autistics these protections take the form of being enfolded by the autogenerated sensations of their own body. In terms of their mode of protection, I call these children encapsulated children.
• (b) The childhood schizophrenics generate a protective illusion of being enfolded inside a body other than their own (usually that of the mother), this other body scarcely being experienced as alive. Cultivating the illusion of sheltering inside someone else’s body means that these children feel confused and entangled with other people. This is not a genuine relationship, although to the superficial observer it might look like one. In terms of their mode of protection, I call them confusional entangled children. (Margaret Mahler called them symbiotic.) With these children, since there is some awareness of bodily separateness, patchy and confused psychological development takes place. However, this is not the case with the childhood autistics, with whom psychological development has virtually stopped (except in those rare cases where it takes place along an isolated, restricted line).

Some children use a mixture of these two forms of protection. Also as treatment proceeds autistic encapsulated children may begin to use confusional entanglement.

A Common Factor in Childhood Psychosis

Dr James Anthony (1958) attempted to find a significant diagnostic feature common to all types of childhood psychosis. To do this, he analysed the records of one hundred psychotic children seen by him at the Maudsley Hospital in London. After several abortive attempts with other features, and after careful trials, he decided that autism was the common feature he had been looking for. Anthony was using the term ‘autism’ to designate a set of processes which excluded reality, and so produced the clinical picture we term ‘psychotic’. In the light of the way in which the use of the term ‘autism’ has been evolving over the intervening years since James Anthony wrote his paper, and the present tendency to restrict the use of this term to designate specific syndromes centred around childhood autism, I would suggest that it is more specific to say that overdeveloped auto-sensuousness is the common diagnostic feature in psychogenic childhood psychosis. In psychotherapy, when working at depth, we find that this over-development of auto-sensuousness has developed to deal with the endogenous ‘psychotic depression’ arising from traumatic experiences of bodily separateness.

In the early days of work with psychotic children, childhood autism and childhood schizophrenia were often not clearly distinguished from each other; this was the case, for example, with Dr Mildred Creak’s well-known ‘seven points of autism’ (1961). However, as Sheila Spensley (1989) has pointed out, in recent years the differences between these two psychotic disorders have become increasingly recognised. Spensley writes:

Kanner, himself, was interested in the similarities between the withdrawal states of schizophrenia and those found in autism, and he even expressed the view that the two would ultimately be linked. Far from supporting this prediction subsequent research has, conversely, drawn attention increasingly to the many differences and contradictions existing between the two. That schizophrenia throws little light on autism has been firmly established. However, it does not necessarily follow that autism cannot illuminate schizophrenia

(Spensley, 1989, p. 237; emphasis added)

(In the above passage, Spensley is using the term ‘autism’ to designate specific psychotic syndromes centred around Early Childhood Autism.)

I have found that childhood autism can illuminate childhood schizophrenia, in that the auto-sensuousness of the encapsulated autistic child is much simpler than that of the confusional entangled schizophrenic-type child, whose auto-sensuality is much more confused. In the course of psychotherapy of the kind described in this book, the auto-sensuality of autistic children is laid bare, and its origins can be traced and deduced. This study of the origins of auto-sensuality highlights the role of primary sensuousness in the psychological development of human relationships.

Primary Sensuousness

Psychotherapeutic work with autistic states in children indicates that the flux of sensations which constitute the infant’s primary sense of being has two main head-streams. There is sensuousness, which is directed towards the body of other human beings who are experienced as responsive and alive; and there is auto-sensuousness, which is directed towards the subject’s own body, or parts of other bodies experienced as if they were parts of the subject’s body. As was indicated in Chapter 2, infant observation suggests that in normal development, from the beginning of life, the consciousness of the very young infant flits, in a flexible way, between these two states. But trouble is in store if auto-sensuousness becomes over-reactive and over-developed. Such abnormal over-reactive auto-sensuous developments mean that primary sensuousness is distracted away from becoming focused on succouring nurturant figures, and thus from developing relationships with them. The tragic state of autistic children brings home to us the importance to psychological development of primary co-operative sensuous relationships. One of the first co-operative interactions of the human infant is sucking at the breast (or bottle). This is the basis for later co-operative relationships. Feeding difficulties are invariably reported in the early infancy of autistic children, and later on they are ‘faddy’ feeders; for example, one feeding difficulty often observed is that of eating only soft foods and rejecting hard lumps. An outstanding characteristic of all autistic children is that they cannot or will not co-operate with anybody. Some of them are very malleable in a catatonic way, and will allow their limbs to stay in the position in which they are arranged by other people, or they will stay sitting in the position in which they have been put down. But this is not co-operation. Co-operation is not part of the pattern of their responses, for this requires some awareness of bodily separateness, and autistic children have developed auto-sensuous protections to avoid experiencing this.

This lack of co-operation is obviously a serious lack in terms of the ontogenetic development of these children, but it is a lack in evolutionary terms also. Human beings are tribal animals, and the ability to co-operate with other members of the tribe has been an essential feature in our successful evolution. At depth, we find that autistic children are ‘red in tooth and claw’, and have a dread of pre-conceptual rivals who seem similarly vicious. (In Autism and Childhood Psychosis (1972) I used the term ‘innate forms’ for such pre-conceptual in-built constellations.) The terror of these ‘pre-conceptual rivals’ is a devastating hindrance to their psychological development. Without the civilising support of the ability to co-operate with other members of their human ‘tribe’, these children are at the mercy of these in-built ‘preconceptions’ of primeval rivals who could never exist in reality, but who nevertheless exert a devastating influence which keeps autistic children trapped in a state of terror. Pathological auto-sensuousness develops to insulate them from these ‘things’ which seem to threaten their very existence. This means that they do not develop co-operation with nurturant figures, in particular with the suckling mother. Instead, their pathological auto-sensuous addiction to idiosyncratic, inanimate objects (to be exemplified and discussed in detail in later chapters) becomes a serious perversion, and is the source of many damaging deficits. These will now be discussed.

The Deficits Arising from Over-Developed Auto-Sensuousness

Stein (1967) and Fordham (1976) have suggested that autism is akin to auto-immune reactions on the part of the body to reject or annihilate alien tissues. They suggest that autistic children have reacted by rejecting or annihilating ‘not-me’ experiences which are felt to be alien and dangerous. This has damaged their development as individuals, in that to have a sense of being a ‘me’ requires some sense of the ‘not-me’.

The over-development of auto-sensuousness is also damaging in another way, in that it blocks normal sensuous experiences with other people. This is as damaging to psychological development as is actual damage to the brain. Indeed, it may even damage the brain, for postmortem investigation of apes who, as infants, had been barred from sensuous co-operative interactions with their mothers has revealed that neural dendrites in the cerebellum had become atrophied. Also, recent work is indicating that stress can produce hormones which damage the brain. This interaction between psychological and physiological factors in the states which are operative in childhood psychosis is one of the factors which makes diagnosis so difficult. As psychotherapists, our study concerns the psychogenic aspects of childhood psychosis. However, we must not be blind to the fact that neurological and hormonal factors may be lurking in the wings.

Now I will continue with the discussion concerning the deficits arising from the pathological over-development of auto-sensuousness.

Deficit in nurturing

Excessive auto-sensuous reactions prevent the child from receiving the nurturing which is almost invariably available, although in varying degrees. Since these children presented a picture of being unnurtured, some workers who observed them in the early days of studying autistic children thought that the parents had been cold and neglectful. My findings show that the actual situation is infinitely more complicated and subtle, and varies from child to child. Most autistic children have not experienced coldness, neglect or physical violence from their parents. For a great variety of reasons, different in each child and intrinsic to the constitutional nature of each, these children have retreated to the sensual fastness of their own bodies and have become insulated from outside influences. Inbuilt patterns with which they were endowed have become operative in a bizarre way unmodified by nurturing influences. Such children become more and more out of touch with any reality which they can share with other human beings. They become increasingly isolated in a state of insulation dominated by their idiosyncrasies and stereotypes. Thus, they pr...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• List of figures and tables
• Acknowledgements
• Preface to the revised edition
• Introduction
• Part I Childhood psychosis
• Part II Psychodynamics and treatment of autistic states
• Part III Clinical studies
• Concluding remarks
• Afterword
• References
• Name index
• Subject index