Autistic Barriers in Neurotic Patients

Frances Tustin

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429911156
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

"Tustin deals very sensitively and sensibly with the knotty problem of parents' contribution to autistic development, providing a balanced interactive view which does not allocate blame. Her discussion of autistic objects and autistic shapes is illuminating and has widespread clinical applicability. This book is highly recommended reading" - Mary Boston, British Journal of Medical Psychology.

PART ONE
PSYCHOGENIC AUTISM

Autistic children are diagnosed by their behaviour or, sometimes, lack of it. In their severest state they do not speak, or only echo what someone else has said, either immediately or after a period of time (delayed echolalia). If they move about (some will sit all day long motionless or producing one activity such as lifting and dropping an object), they usually appear uninterested in their surroundings.

In fact, the behaviour of severely autistic children, unlike that of all except the most severely brain-damaged child, appears purposeless, but compares notably with that displayed by animals reared in strict isolation. Attempts to interest them in alternative behaviour are usually avoided or actively resisted, and can produce severe tantrums or attempts to escape the situation. They appear to have no sense of identity, and to inhabit an empty world.

Brian Roberts, Introduction to Furneaux and Roberts (eds), Autistic Children, p. 10

CHAPTER ONE
The nature of psychogenic autism: an overview

My mother groan’d, my father wept,
Into the dangerous world I leapt:
Helpless, naked, piping loud:
Like a fiend hid in a cloud.

Struggling in my father’s hands,
Striving against my swaddling bands.
Bound and weary I thought best
To sulk upon my mother’s breast.

William Blake, ‘Infant Sorrow’

No one would dispute that psychogenic autistic children are hard to reach. Indeed, the dispute might be as to whether they can be reached at all. However, it was my experience, as I became increasingly in touch with their idiosyncratic mode of functioning, that some young autistic children (though not all) could be reached by psycho-analytically based psychotherapy. However, before discussing psychogenic autism, let me say a word about the organic hypothesis.

The organic hypothesis

I respect the concern of the organicists who feel that it is irresponsible to raise hopes in parents who have already suffered so much. It is regrettably true that in the early days, following Kanner’s distinguishing ‘early infantile autism’ from mental deficiency, in an outburst of enthusiasm, psychoanalysts and psychotherapists made unjustified claims for the possibilities of the psychodynamic treatment of autism. Even today, in some quarters, the psychodynamicists do not make a clear distinction between psychogenic and organic autism, nor between autistic-type and schizophrenic-type disorders, and disorders arising from parental neglect.

Some autistic children are undoubtedly brain-damaged, and thus have a cognitive defect. However, the organic hypothesis - that they have a genetic defect in terms of a ‘fragile chromosome’ - does not seem to have been borne out by attempts to replicate the treatment suggested for it. But these neuro-physiological matters are not really my concern. As a psychotherapist, those children whose autism seems likely to be psychogenic in origin have been the focus of my attention. For those readers who have never worked with psychogenic autistic children, here is a brief description of them.

Description of psychogenic autistic children

Such children seem to be in a massive, unmitigated primal sulk such as was described by Blake at the head of this chapter. But it is a much more intense sulk than that described by Blake. As we shall see in later chapters, it is shot through with umbrage and black despair such as have been described by Ted Hughes in Crow. This has caused them to be unrelated to the mother, and thus to people in general. They avoid looking at people, and communication by language, play, drawing or modelling is scanty, and often not present at all. The children I have treated have all been mute at the outset of treatment, but some autistic children are echolalic so that they communicate in a limited but bizarre way. These latter children also sometimes ‘play’ in a restricted, obsessional way. The late Margaret Mahler, in illuminating papers and books arising from her long experience with such children, has focused attention upon autistic children’s difficulties concerning separation and individuation, and their fragile awareness of their own identity (Mahler, 1958). Such children lack empathy (see Hobson, 1986). They also lack imagination (see Frith, 1985). These children have no inner life. To ascribe fantasies to them is incorrect. This makes psychotherapy with such children different from that with our other patients. Overall there is a gross early arrest of cognitive and affective development, although autistic children’s physical development is usually normal. Indeed, they often have beautiful faces and well-formed bodies. Let me embody this description in a flesh-and-blood child patient who illustrated many of the features characteristic of psychogenic autism.

A consultation with an autistic child

Six-year-old Stephen is brought to see me in my consulting-room. He makes no complaint about coming. He has on a shiny white plastic mackintosh with a zip up the front. He carries a toy car clutched tightly in the palm of his hand. His mouth, which is slightly open, seems limp and slack, but his body feels tight and hard as I guide him into the room. He is mute. Stephen stands before me with a well-formed body, an otherworldly look and melancholy eyes which do not meet mine directly. Whilst I wrestle to undo the zip of his mackintosh, he stands stiff and inert like a statue. He does not co-operate with me in any way. In fact, he seems to be oblivious of me. However, when I have half undone his zip, he steps out of the mackintosh and, still avoiding looking at me directly, retreats to a remote corner of the room, hastily grabbing a brown crayon from the table as he does so.

In the corner, with this crayon, he immediately starts to draw large sweeping lines on the floor in front of his feet. I feel more and more cut off from him as he multiplies the encircling lines around him. At last, I take his plastic mackintosh from the chair and hold it in front of me. Although he seems so unaware of me, he is aware of this and runs forward to dive into the protection of the mackintosh like a snail returning to its shell.

Stephen shows many of the features which are typical of autistic children. There is the avoidance of direct eye-to-eye contact with me, although he has a fringe awareness of what I am doing. He does not co-operate but cuts himself off from me. He leaves his mother without a backward glance and shows none of the normal responses to people. Physically, he is well formed and his face would be attractive were it not so expressionless. This is the case apart from his eyes which sometimes look anguished and melancholy. He carries a hard object clutched tightly in the palm of his hand.

I call autistic children ‘shell-type’ or encapsulated children. Their parents often say such things as ‘I can’t reach him’. ‘My child seems to be in a shell all the time.’ ‘It’s as though he can’t see or hear us, or won’t.’ Such children are often thought to be deaf and some even try to walk through objects as if they were blind. However, on being tested, their perceptual apparatus is found to be intact; it is the processing of incoming information which is faulty. This could be due to brain lesions or to psychogenic damage. (Clinical work has given me clues as to the nature of the psychogenic damage, which will be discussed in various chapters throughout the book.)

This psychogenic damage causes autistic children to turn their attention away from the things that the developing child usually attends to. This seems to be because they are protecting their bodies from ‘not-me’ threats which are felt to be overwhelmingly dangerous. When working with these children, it becomes clear that anything which is not familiar, and is ‘not-me’, arouses intense terror. A grown man of twenty-five, who had been diagnosed by Leo Kanner at age four as suffering from early infantile autism, said that his outstanding memory of the autistic state from which he had emerged to some degree was of ‘terror’ (Piggott, 1979).

In certain neurotic patients, both children and adults, the autistic features which have just been described and exemplified are overlaid by more normal functioning. The instability of this becomes apparent as work at depth proceeds.

The origins of psychogenic autism

Clinical work with psychogenic autistic children in whom no brain damage can be detected by the investigative methods at present available indicates that they developed, as infants, a massive formation of avoidance reactions in order to deal with a traumatic awareness of bodily separateness from the mother. This impinged upon their awareness before their psychic apparatus was ready to take the strain. You will notice that I am emphasizing the organizational state of the infant rather than the age at which the trauma occurred. This is because, in some infants, the impingement occurred following a too-close association with the mother which went on for too long, whereas in other infants it occurred in earliest infancy. Winnicott (1958) has described this latter situation as follows:

...certain aspects of the mouth...disappear from the infant’s point of view along with the mother and the breast when there is separation at a date earlier than that at which [the child] had reached a stage of emotional development which could provide the equipment for dealing with loss. The same loss of the mother a few months later would be a loss of object without this added loss of part of the subject.

In terms of Stern’s recent formulations concerning the development of self (1986), a traumatic awareness of separateness occurred in the state of being an ‘emergent self, and before ‘the core of the self had developed. In other words, it occurred before the suckling mother, and all that this implies, had become well established as an inner psychic experience and before a secure sense of ‘going-on-being’ had developed. Thus, these patients are beset by such elemental dreads as falling apart, of ‘falling infinitely’ (Winnicott’s phrase), of falling with a damaging bump, of spilling away, of exploding away, of losing the thread of continuity which guarantees their existence. These terrors were experienced in a state which was preverbal, pre-image and preconceptual. They meant that the infant’s emotional and cognitive development was either slowed down, or virtually stopped.

In a hidden area of their personality, certain neurotic patients feel helplessly immobilized and at the point of death. They are always trying to counteract this deathly arrest to their ‘going-on-being’ by overreaching themselves and by having unlimited expectations of themselves and of other people. Since they are usually well endowed they achieve a great deal, often of a cerebral nature, but it is at great personal cost. Two dreams of an intelligent man who coped efficiently with a professional job vividly portray such autistic handicaps.

In the first dream, the dreamer was standing on the raised veranda of a house looking down on a large expanse of water through which a boat was very slowly making its way. The progress of the boat was so slow that the season changed to winter and the boat became frozen into the ice. The dreamer noticed the rotting timbers of the boat. He set out in a snowmobile to release the boat but he went so fast that he overshot it. This means that he went to the edge of the expanse of water which was now reduced in size from being a sea to being a lake. Also, the boundaries of this lake were obliterated by the snow that had fallen, so that the differentiation of land from water was obscured. The dreamer went on trying to get to the boat by other means, but he was always foiled in his attempts by obstructions and confusions.

In the second dream, the dreamer saw a man falling from an open window to the ground which was hard and damaging. Before the surgeon could finish attending to his injured legs, the falling process was reversed and, as sometimes happens in films, the man shot up again, to fall from the open window as before. But this time he had heavy casts on his legs which seemed to be made of concrete. These made him fall faster and more heavily than before, so that when he landed his injured legs were embedded in the ground and he was immobilized like the boat.

Discussion of autistic immobilization

These two dreams poignantly illustrate the autistic encapsulation which develops to encase and immobilize the damaged part of the personality which is concerned with understanding. Over-concretized thinking becomes the order of the day; the capacity to make the abstractions necessary for imaginative and reflective thought is restricted. The second dream also brings in the notion of the catastrophic fall which provoked these autistic reactions. Dreams are the only way neurotic patients can tell us about this catastrophe. It is fortunate that they can use the image-making capacities of the non-autistic part to do so. However, when they can talk, young autistic children can tell us about this tragedy more directly (see the material of John in Chapter 4).

The Fall from the sublime state of blissful unity with the ‘mother’ who, in early infancy, is the sensation-dominated centre of the infant’s universe, is part of everyone’s experience. However, for some individuals, for a variety of reasons, different in each case, the disillusionment of ‘coming down to earth’ from this ecstatic experience has been such a hard and injurious experience that it has provoked impeding encapsulating reactions. It has been the pebble which provoked the landslide. The encapsulating reactions support and protect the damaged part and shut out the fear of being killed but, metaphorically speaking, their psychic functioning is frozen and immobilized. There is no flow. Also, in the first dream, the dreamer was observing these experiences as happening outside himself. He was in an elevated state looking down upon them. In the second dream they were happening to someone else. Such ‘out-of-the-body’ experiences counteract the threat of dying. In most cases, the threat is of worse than death. It is the threat of total annihilation.

Encapsulating reactions mean that in an isolated area of the personality, attention has been deflected away from the objective world which presents such threats, in favour of a subjective, sensation-dominated world which is under their direct control. In certain neurotic patients (and, as Sydney Klein says, some of them are only ‘mildly neurotic’), this has become an established way of life. These avoidance reactions, which were necessary at the time of the catastrophic Fall, but which have outlived their usefulness, become autistic barriers to cognitive and affective functioning. The effort to keep going and to maintain an appearance of normality is very hard work. In an isolated area of their being, such patients feel that their life goes in ever-decreasing circles, as is shown by the sea which shrinks to being a lake.

The Fall and its accompaniments tend to be repeated in later life situations where ecstatic expectations have been built up to be dashed to the ground by contact with reality. Thus, they can occur in such situations as giving birth to a baby, in the midlife crisis, after the ‘honeymoon period’ of marriage, in psychotherapy or psychoanalysis ... Such people compensate for their unacknowledged sense of being irreparably damaged by perfectionist expectations of themselves and of other people. When these impossible expectations are disappointed, the infantile experience of damaging disillusionment is re-evoked. At the base of their being they live in an ‘all or nothing’ world. It is an uncompromising black-and-white world in which opposites cannot be tolerated because they seem to threaten to destroy each other. These fears lead to narrow-mindedness, to bigotry and fanaticism. They may be covered up by so-called ‘progressive attitudes’, often of an extreme ideological nature. The instability of these extreme attitudes sometimes becomes apparent when there is a sudden switch to those of a totally opposite kind.

Primary psychic mishaps also lead to an obsessional need to feel in control of what happens. They may also lead to phobic reactions. A phobia is terror of a specific part of the outside world, usually of one that has been attractive to the individual, whereas autism is terror of almost the whole of the outside world, particularly of the mother. When phobic patients are analysed at depth, we are likely to find that bodily separateness from the mother has been experienced as an insufferable catastrophe. This will be illustrated in various chapters in the book. This catastrophe is also at the heart of the manic defence. There are even some so-called borderline patients who are so frozen with terror that they do not know what feelings are, a condition now termed ‘alexythymia’ (Grotstein, 1983). At this point, I want to link what I have been saying to the findings of other writers, so that readers with a different orientation from my own may find themselves in familiar territory.

The findings of other writers

In the quotation cited earlier Winnicott described such catastrophic separation experiences. He sees them as resulting in what he calls ‘psychotic depression’. This type of depression is associated with a sense of collapse - of what Winnicott (1958) calls ‘flop’. Edward Bibring, who has focused on the feelings of littleness and helplessness, calls it ‘primal depression’ (Bibring, 1951.) Spitz writes of ‘anaclitic depression’ (Spitz, 1960). Balint has written about such patients’ ‘basic fault’ (Balint, M., 1968). Bion writes of a ‘psychological catastrophe’ (Bion, 1962b). Influenced by Bion and also, of course, by Freud, James Grotstein has described such patients’ main ‘deficit’ as the lack of a ‘filter’ for incoming and outgoing stimuli (Grotstein, 1980). The behaviourists write of autistic children’s incapacity ‘to encode and process information’. They see this as arising from an ‘innate cognitive defect’.

Acquired cognitive and emotional defects

This chapter has indicated that cognitive defects (as also emotional defects, with which they are intertwined) are not always innate but can also be acquired. All the chapters in this book are concerned with how this can occur. The basic thesis is that the autistic state is a reaction to a traumatic awareness of separateness from the sensation-giving suckling mother. Autistic reactions divert attention away from this mother, who is spurned in favour of self-generated sensations which are always available and predictable, and so do not bring sh...

Table of contents

• Cover Page
• Half title
• Copyright Page
• Acknowledgements
• Dedication
• Contents
• Foreword
• Preface
• Introduction
• Part One Psychogenic Autism
• Part Two Psychogenic autism in neurotic patients
• Concluding Remarks
• Bibliography
• Index