Autistic Barriers in Neurotic Patients

AUTISTIC BARRIERS IN NEUROTIC PATIENTS

AUTISTIC BARRIERS IN NEUROTIC PATIENTS Frances Tustin Child Psychotherapist and Honorary Affiliate of the British Psycho-Annlyticnl Society

Foreword b y

James S. Grotstein

London

KARNAC BOOKS

Drawing by J.F. Batellier, reproduced from Is Anybotiv Ozrl There:) courtesy of Free Association Books. Ted Hughes' poem 'Wodwo' is reprinted from Wo&-o by perlnission of Faber and Faber Ltd. Verses from ' I an1 a Rock' are reproduced by kind permission of Mr Paul Simon. O Paul Simon, 1965.

First published in 1986 by H. Karnac (Books) Ltd. Karnac Books Ltd. 6 Pelnbroke Buildings 118 Finchley Road London N W I0 6RE London NW3 5HT Second impression 1994 Reprinted 2003

O 1986 by Frances Tustin All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means. electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher.

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ACKNOWLEDGEMENTS

11but three of the papers that compose this book have been written since the publication of my last book, Autistic States in Children. An invitation to speak to a receptive audience inevitably engenders new thoughts, so my gratitude goes out to the various organizations who have welcomed me into their midst. The book also owes a great deal to those psychoanalysts mid psychotherapists from England and abroad who have consulted me about their work and have generously allowed me to use their observations. When they presented their work to me, they were often not aware of the new thoughts that were stirring in my mind; their work and the discussions I had with them either confirmed or modified what I was thinking. I am grateful to these people for their carefully recorded material and for the discussio~~s I had with them. They are too numerous to nlention individually, but they will know who they are, and I take this opportunity to thank them. As always, gratitude is felt towards my husband for raising uncomfortable question-marks in niy mind about the conclu-

vi

AUTISTIC BARRIERS IN NEUROTIC PATIENTS

sions I was drawing from my observations. These have opened doors to increased insight. The effort to think about such questions lights a lamp in the mind which helps in facing the inevitable areas of darkness imposed by one's own human limitations. Warm thanks are also due to Miriam and Alex'mder Newman of the Squiggle Foundation, wlno have always been on hand to help me in situations of crisis. I also want to thank my friend Victoria Hamilton for giving me a complete copy of Tennyson's In Memoriant. and for all tlne helpful discussions I have had with her. These acknowledgements would not be complete without mentioning Professor Adri'ulo Giannotti, wlno now has the Chair of Child Neuropsychiatry in the Institute of Childhood Neuropsyclniatry of Rotnle University, and his co-workers, who have welcomed me every year for the past ten years to give papers to well-attended conferences. Work with this well-endowed institute, in which autistic children are investigated from tlne metabolic, organic, psychotherapeutic, and educational points of view, has extended my knowledge of autistic children. I am grateful to Dr Decobert of the Clapar&de Clinic in Paris, and to Dr Genevieve Haag, Leni Iselin, and Dr Anik Maufras de Chatellier for their support and invitations over many years. Dr Viky Subirana, Medical Director of Carrilet Unit for Autistic Children in Barcelona, is remembered for her warm welco~nneto me and to my ideas. I am also grateful to the California Institute of the Arts and tlne Continuing Education S e m i n m of Los Angeles for their encouragement and the videos they have made of my presentations to them. I must also acknowledge with thanks the per~nnissionfro111 the editors of the Inter-national Review cf Psycho-Analysis, Journal of Child Psychology and Psychiatry. BI-itishJournal of Medical Psychology, Journal of Child Psychottrer'apy, Patio, and Topique to reprint papers originally published in their journals.

ACKNOWLEDGEMENTS

vii

I should also like to thank Ann Scott for her careful and facilitating editing of this book. Finally, I am grateful to Harry K'u~lacand Cesare Sacerdoti for giving me the privilege of preparing a book which I knew had a publisher enthusiastic to receive it, and who would expedite its publication. Last but not least, I want to thank Audrey Franklin and Mrs. G. Soloman, who have typed these papers so accurately and-expeditiously. Frances Tustin

March 1986

This book is dedicated to the sad and terrified children from whom I have learned so much, and also to their parents who have supported me so valiantly

CONTENTS

v

ACKNOWLEDGEMENTS FOREWORD

by James S. Grotstein

xiii

Preface (1 994) Introduction

PART ONE

1

2

3 4

Psychogenic autism The nature of psychogenic autism: an overview The growth of understanding: a personal statement Thoughts on psychogenic autism with special reference to a paper by Melanie Klein A significant element in the development of psychogenic autism

19 33 48 67

xii AUTISTIC BARRIERS IN NEUROTIC PATIENTS 5 6 7

8 9 10

Situations which may precipitate psychogenic autism Autistic objects Autistic shapes exemplified in childhood psychopathology Autistic shapes exemplified in adult psychopathology Shapes associated with emergence from psychogenic autism A glimpse into the world of an autistic child

PART TWO

11 12 13 14

15 16

Psychogenic autism in neurotic patients Falling Spilling and dissolving The development of 'I-ness' Anorexia nervosa in an adolescent girl The rhythm of safety Psychotherapy with psychogenic autistic states

Concluding remarks

BIBLIOGRAPHY INDEX

94 102 119 141

157 170

FOREWORD

b y James S . Grotstein

nfantile autism, once located in the obscure outback of the mental health field, has recei~tlycome into welldeserved prominence because of the pioneering contributions of several distinguished investigators who have spent a great portion of their lives in the clinical investigation of this disorder. Leo Kanner (1949) did yeoman's service in separating infantile autism from mental retardation. Following this, Margaret Mahler (1958) recognized the differences between infantile autism and infantile symbiosis and then postulated that these disturbances represented pathological extensions of what she proposed to be normal, successive stages of infant development, each of which paved the way for the separation and individuation of the child. Then Donald Meltzer and his colleagues published a significant monograpl~(1975) which detailed the phenomenology of infantile autistic psychosis and helped us to understand it from an intrapsychic point of view. They postulated that the infant who is to become autistic recognizes the presence of depression in his or her mother and,

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AUTISTIC BARRIERS IN NEUROTIC PATIENTS

as a consequence, dismantles his or her own ego, particularly those capacities that knowingly depend upon mother for their welfare. The autistic children dismantle their dependencyaware egos allegedly so as not to jeopardize their depressed mothers further. Illusory autistic autonomy is the result. Frances Tustin has more recently joined this distinguished group of investigators of autism and has already made contributions that have not only greatly increased our knowledge about the nature of this disorder and how to treat it but, perhaps even more significantly, have brought the concept of autistic enclaves into the very centre of our concept of neuroses as well as other more common psychopathological disorders. Moreover, she has nude formulations which, if accepted, may help to alter some of our fundamental conceptions about infant development itself. The present work comprises a series of papers, most of which were published subsequent to her latest book, Autistic States In Children (1981). They continue the thrust of this earlier work 'and also constitute clarifications and modification of her rich ideas. In addition, they offer some significant newer ideas about autism, not only in infants and children, but also ill adults, particularly in such entities as neuroses, phobias, anorexia nervosa and other eating disorders, substance abuse, and perversions. Frances Tustin's wellspring is that of Melanie Klein and Wilfred Bion, but the range of writers she draws on is noteworthy-Winnicott, Bowlby, Meltzer, Erikson, Mdller, and also, poignantly, such poets as Tennyson, MacNeice, Plath, Eliot. Hughes, and Yeats. The reader is therefore presented with a patchwork quilt of many colours but one which nevertheless achieves har~nony,texture, and quality. In her earlier works, particularly Autistic Stares in Children. Frances Tustin emphasized two childhood psychotic entities, the encapsulated or shell-type child and the confusional or entangled child. The former constitutes infaantileautistic illness proper, and the latter, symbiotic or schizophrenic psychosis of childhood. She described the encapsulated child as a being

FOREWORD

xv

characterized by the use of hard autistic objects, which differ from transitional objects both in their aim and in the technique of using them. Autistic objects are employed by the encapsulated autistic infant in an idiosyncratic and surreptitious manner to soothe himself in his isolation; they are not meant to maintain the illusion of bondedness to the mother in her absence. Thus, according to Tustin, transitional objects are object-related, and autistic objects are purposely nonobject-related. The confusional child, on the other hand, is characterized as employing soft objects in order to 'mop up' the experience of woundedness. Both types of autistic child have in common the experience of a process of 'premature mental birth', which propels them into a world of precocious sep'uateness from their mothers without the requisite individuation that this cataclysmic separation would ordinarily entail. The encapsulated children protect themselves from this cataclysm by developing an imaginary hard shell to shield their hypersensitive surfaces from the hostile, dangerous impingements of all 'not-me' experiences, primary among which is that of the 'stranger/mother'. The confusional child, on the other hand, seems to t'ke the opposite course, becoming inextricably bound in the substance of mother, confused with her, so as not to be separate. In this present work, Frances Tustin concentrates more on encapsulated children, reiterating her belief that they have experienced 'premature mental birth', that they are probably born with a hypersensitivity to life, and that they frequently have experienced impingement by mothers who suffered from depressive illness, a fhding that Meltzer and his colleagues had also noted (1975). Confusional children, Tustin now believes, may have developed a maternal bond and then regressed from it. Further, she now states that the autistic encapsulated child is not psychotic by virtue of his or her encapsulation; in fact, this seenls to protect this type of child against the psychosis that charncterizes the confusional child. What I find to be of particul'u significance in Frances Tustin's present work is her elaboration of aurosensuousness,

xvi

AUTISTIC BARRIERS IN NEUROTIC PATIENTS

a phase of development which she now suggests occurs normally prior to autoeroticism and autosadism and is followed in turn by narcissism. The emphasis in classical psychoanalysis has clearly shifted lately from neuroses to more primitive stages of development, and narcissism seems to have emerged as the commonly designated term to embrace them. Melanie Klein had been there all along with her psychoanalytic conception of internalized objects and the infant's identifications with them, which constituted her version of narcissism. Klein, however, as Tusti~lpoints out, dealt with infants who were thought to have been already bonded with their motliers and, consequently, to have developed psycliopathology in proportion as they attacked (or believed ~ J phantasy I that they attacked) those bonds, metaphorically represented principally as the breast. Tustin suggests that Klein's psychology applies to symbiotic or schizophrenic-type children, not to autistic ones. Here, she is explaining a stage that is more primitive th'm bonding, a state already alluded to by Fairbairn's description of the schizoid position (1952). by Bion's theory of infantile catastrophe (1970). by Mahler's idea of infantile depression (1966), and by Winnicott's of 'failure to go-on-being' (1958). In my own writings, I have referred to this stage as that of inchoate randomness or meaninglessness awaiting the mother's loving signification to give the i11fa11t its tneaningfuh~essand thus to rescue him or her from the 'abyss of the deep and formless infinite'. Two other followers of Klein, Esther Bick and Donald Meltzer (1968), had already made forays into this earlier era of mental life when tliey posited that some of their autistic children showed developmental arrests which occurred even earlier than Klein's paranoid-schizoid position. They termed this adhesive identification and postulated tliat these children suffer consequently from adhesive identity, by which they tneai tliey have no sense of identity of their own mid achieve a tentative 'as if' identity by adhering to solid surfaces, including the surfaces of their mother's body, at first concretely and later metaphorically.

FOREWORD xvii Frances Tustin's conceptualization of autosensuousness seems to give important perspective to this newly discovered phase of infant development and is undoubtedly being conf m e d at this time by empirical itlfiult observation. Of particular importance for clinical psychoanalysis and psychotherapy, however, is her postulation of critical deficits in this primitive stage, an area that she has explored extensively over decades. I understand her to suggest that encapsulated autistic children in particular demonstrate a pathological, abrupt rupture of autosensuousness so that, whereas normal autosensuousness and subsequent development into sensual differentiation and integration ultimately link to bonding with objects through the senses separately and together, pathological autosensuousness has cut the cord, so to speak. Herein lies the brilliance of Tustin's contribution, I believe. She states that, in effect, the encapsulated autistic child seems never to have developed a viable, sanguine sensuous colltact with its motlier because of its experience of premature mental birth. It felt too existentially alone too early and therefore became sealed off by this very aberrant, involuted autosensuousness. Thereafter, tlie objects of the senses are no longer tlie desired and needed mother; instead, they are tlie sensuous pllantoms of the sense organs themselves; the autoclitl~onous'objects' that autosensations now patllologically create on their own become the new-found 'objects' of the encapsulated child. Frances Tustin's first discovery in the area of deviant autosensuality was in relation to autistic objects, hard objects barred from the outside or objects from the self (the tongue, faeces, extensions of the inner tilucosa of the mouth, etc.) which would, by their reassuring hardness, seemingly, 'plug up the holes above their inner emptiness'. Her later discovery, elaborated in the present work, is that of autistic shapes. Thus, clutchblg an object tightly produces hard object-like sensations, whereas stroking or holding an object loosely produces evanescent shapes soothing to the encapsulated child. Thus, such a child seems trapped in an empty fortress surrounded by

xviii AUTISTIC BARRIERS IN NEUROTIC PATIENTS a wall of pathological autosensuousness which conjures up hard object-like sensations 'and soft idiosyncratic shapes to reassure the child, wlio is now cut off from humui contact. Mention should also be made of Tustin's emphasis on the importance of dentition as a catastrophic landmark in the development of autistic children. Apparently, the transforniation from the sucking inf'ant to the biting infant is a critical one and seems to inspire the emergence of atavistic phantasies belonging to the preylpredator category. According to Tustin, predator anxiety beconies intimately linked 'and confused with all 'not-me' experiences and associated with the experience of infantile depression. To that, I would add infantile panic disorder. It therefore becomes more understmidable that these children should hide behind their shells, involute developmentally back into tlien~selves,mid compulsively manipulate their objects, both autistic objects mid hum'an 'not-me' objects, into being their servants-so that they do not have to leave the capsule and experience disaster while servicing their needs. In this regard, Tustin's observations display tlie origins of perversions, both physical a i d cyclical, froni tlie ~iiostunique arid credible perspective. These ideas might seen1 to be recondite and confined to the limited area of infantile autistic illness, were not Tusthi's ideas so credible when linked to more comn~onlydiscussed adult psychopathology. Dr Sydney Klein, a fellow traveller of Frances Tusthi's, had already made a contribution along these lines, and she greatly elaborates on his contribution in the present work. Pathological autosensuousness can clearly be seen, for instance, in patients with anorexia nervosa who can be thought of as having erected mi imaginary autosensuous shell around them to keep out 'not-me' food from the outside world. Again, it can be seen in the behaviour of a patient of mine, a dutiful housewife wlio shunned sex mid obsessively engaged in meaningless crossword puzzles till late in the night while by day she distracted herself with meaningless bookkeeping-all to keep her emotions at bay as well as her awarenesses of need for her husband and her analyst. Another

FOREWORD xix patient of mine, a man in his late fifties who had been mamed five times, revealed a dream in which one of the features was a concrete bathroom. His associations led to the need for privacy aid insulation, from which developed a history of pseudocontact with people but with a sense of detachn~ent from them. Where he really lived was in his concrete bathroom of isolation. The sub-clinical encapsulated child probably continues on in tlie wide variety of alexithyniic disorders and the whole gamut of those suffering from schizoid detachment, whereas the sub-clinical confusional child s e e m to live on as borderline with narcissistic personality disorders and, in particular, in the new category known as hysteroid dysphoria, an entity known for its particular hypersensitivity to object loss and its compensatory use of objects in an entangled, addictive manner. While there is some similruity to Winnicott's concept of the 'true selflfalse self', Tustin has amended her views about this correlation in her present work, She now finds that the phenomenon she designates is even deeper than 'true self/false self' insofar as autistic children have never even developed a sense of self; they have only a neuronientd ego looking for a self, but never finding it because of tlie barricade erected by their autistic autosensuousness. Even more profoundly, Frances Tustin's research allows us to penetrate to a level of meaning beyond cognition, beyond instincts, beyond emotions, even beyond phantasy; she has given us a glimpse into the very roots of perception and has thereby elevated (auto)sensuousness to its deserved signific~mce. This is an important work and also a most enjoyable one to read. I am sure that many readers will feel, as I did, 'That applies to a patient of mine; this applies to another patient. Hey, wait a minute, that applies to tne !'

xx

AUTISTIC BARRIERS IN NEUROTIC PATIENTS

REFERENCES Bick, E. (1968). 'The experience of the skin in early object relntions'. International Journal of Psycho-Analysis, 49: 484-486. Bion, W. R. (1970). Attention and Interpretation. London, Sydney, Toronto, and Wellington: Tnvistock Publications. meprinted London: Kmnac Books, 1984.1 Fairbairn. W. R. D. (1952). Psyckoanalytic Studies of the Personality. London, Henley and Boston: Routledge & Kegan Paul. Kanner, L. (1949). 'Problems of nosology and psychodynamics of enrly infantile autism'. American Journal of Orthopsycltiutry, 19: 41-26.

Klein, M. (1950). Contributions to Psycho-Analysis 1921-1945. London: The Hogarth Press and the Institute of Psycho-Analysis. Klein, M. (1959). The Psycho-Analysis of Children. London: The Hogarth Press and the Institute of Psycho-Analysis. Mnhler. M. (1959). 'Autism and sy~i~biosis-two extreme disturbances of identity'. International Jorrrnal of Psycho-Analysis, 39: 77-83.

Mahler, M. (1966). 'Notes on the developnient of basic moods: the depressive affect'. In R. M. Lowenstein. L. M. Newman, M. Schur, and A. J. Solnit (Eds.), Psyckoanalysis: Essays in Honor of Heinz Hartmann @p. 152-168). New York: Internntional Universities Press. Meltzer, D. (1975). 'Adhesive identification'. Contenrporary Psyclzoanalysis, 11: 289-3 10. Meltzer, D., Bremner, J., Hoxter, S., Weddell, H.. & Wittenberg. I. (1975). Explorations in Atttisni. Strnth Tny, Perthshire: Clunie Press. Tustin. F. (1981). Atttistic States in Clzilclrcn. London, Henley, and Boston: Routledge & Kegan Paul. Winnicott, D. W. (1958). Collected Pupers: Throligh PaeJiutrics to Psychoanalysis. London: Tnvistock Publications.

An infant crying in the night: An infant crying for the light: And with no language but a cry. Tennyson, In Memoriant. LIII

PREFACE

am grateful to Cesare Sacerdoti of Kamac Books for giving me the opportunity to write a new preface to this second impression of Autistic Barriers in Neurotic Patients. for since this book was first published certain experiences have caused me to think more deeply about the nature of Childhood Autism. Of necessity, what I have to say will be somewhat anecdotal because I shall be instancing recent experiences that have influenced my thinking along certain lines. Revised views on normal printnry auzism After I had given up the hypothesis of autistic illness being a regression to an early infantile stage of normal primary autism ('Revised understandings of psychogenic autism', 1991, and 'The perpetuation of an error', 1994), I made a careful survey of the early histories of my own treatment cases of autistic disorder. As a result of this, I developed the alternative hypothesis that early-childhood autism is a two-stage illness:

2 AUTISTIC BARRIERS IN NEUROTIC PATIENTS the first stage being an unduly close association with the mother, the father often being virtually absent or excluded. Such a child has been described as a 'cork child' to plug the hole of the mother's depression and loneliness (Joyce McDougall, 1986 and 1989). The second stage is when this over-vulnerable, 'hot-housed' child inevitably becomes aware of bodily separateness. This is in such a sudden and painful way for it to seem to be a life-threatening disaster. It is traumatic. Trauma as a precipitant The undue closeness of mother a11d child me'ans that from birth the infant has had the illusion that (s)he was still part of the mother's body. This prevented normal attachment processes from developing. Sudden awareness of their separatedness from each other had felt like being violently wrenched apart. It was experienced as a death-dealing catastrophe of poignant loss. It had been a traumatic 'psychological birth' (1981), following which the mother had not been able to provide the 'mental uterus' the baby needed. Lacking the focus of a secure attachment to a breast that was the source of sensuous satisfaction, post-umbilical susten'mce, and safety has tainted the whole of these children's psychological development. Autistic processes have developed as a reaction to this unbearable elemental trauma of separatedness: the deadening of responsiveness being a reaction which is specific to any kind of trauma. Murderousness as a consequence of trauma and non-attachment My conviction about the appositeness of this hypothesis relating the precipitation of autism to a traumatic experience was strengthened by two broadcasts about serial killers. The milkers of one of these (ITV Chulnel 4, Sunday, 12 December 1993) talked to the parents of a mass killer and were given unique access to audio-taped interviews between hirn and a forensic psychologist.

PREFACE

3

They found that research into more than 200 cases of serial murders had enabled forensic psychologists to create a model of a typical mass-murderer's personality. This had sliown that the behaviour of some serial killers could be traced back to childhood traumas. The traumas of being subjected to physical or sexual abuse, or of experiencing a painful break-up of their parents' mamage, were cited. Tlie elemental trauma of awareness of wounding bodily separatedness such as I had found to have happened to autistic children was not instanced, although Dr John Bowlby's work comes close to this. In his early paper concerning 'Forty-four juvenile thieves: tlieir characters and home-life' (1944), Bowlby traced their delinquency back to early traumas of geographical separation from the mother, such as going into hospital. He described actual experiences of separation fro111 the mother, but these were at an age older than that of the autistic children I have studied. In the second programme about 'Serial Killers' (Radio 4, 3 December 1993), a psychiatrist called Janice Morrison, who had spent hundreds of hours with some of America's most notorious murderers, described her interviews with them. I was particularly struck by her description of these killers as not making tlie distinction between animate and inanimate objects. This is the distinguishing feature of autistic children. For example, Peter Hobson, in his recent book Autism and the Development of Mind (1 993), writes about autistic children as follows: They are relatively successful hi following the I-It developmental pathway. . . It is specifically in 1-Thou interpersonal relatedness that we find the abnormalities characteristic of 'autism'. (p. 197)

.

When Momson investigated tlie early personal history of the murderers, she found that, as infants, many of them had been relatively undifferentiated from their mothers with whom they had been unduly close.

4 AUTISTIC BARRIERS IN NEUROTIC PATIENTS Conzparison of autistic children and serial killers In spite of the differences in the traumas that have precipitated their disorder, both autistic children and delinquents (including mass murderers) have important features in common. They have both experienced difficulties in what Bowlby, influenced by ethology, called 'Bonding'. This notion of 'bonding' is now used in popular speech and was used by the makers of the television programme about serial killers. This early lack of a primal attachment affects the development of relationships to people-the 'I-Thou' approach. As will become clear from this book, clinical work has caused me to see primal attachment as a time when sensuous contraries, such as llard and soft, male 'and female elements, come together as the infant's attention becomes focused upon the suckling mother in a working relationship. The apathy of a depressed mother and possibly a depressed child prevents this resilient contact. Both autistic children and mass murderers are out of touch with people. The makers of the television programme I have cited said:

The future killer fends off unhappiness by suppressing a11 feelings towards family and friends and becomes increasingly isolated. Refuge is found in f'antasies which provide situations which can be controlled. (Article in the Radio Times. 11-17 December 1993, p. 5) Autistic children have no fantasies, iuld their trauma has occurred earlier. However, there are other features that autistic children and mass murderers have in common. They both have trouble in managing their violent feelings. In addition, because they both feel so weak and helpless, they need to feel powerful and in control. Interesth~gly,the forensic psychologists found that killers conlmitted murders when some person had threatened to separate from them. An autistic cltild wlto becantc?nzurderous The mass murderers were usually glad to be arrested and imprisoned. The programme-makers suggested that this could

PREFACE

5

be due to the fact that, after this took place, they received a great deal of attention. It could also be due to the fact that they felt that their violence was being contained. Unlike the autistic children, they have not had the 'prison of autism' to hold it in check. Several years ago, I saw a BBC television film about Bruno Bettelheim's Orthogenic School, in which former pupils of the school talked about their experiences there. One of them (now a professor!) told about an autistic boy in the school. He described, with great sadness, how this boy had given up his autistic controls only to become schizophrenic and murderously violent. [The fact that, as I have previously noted (e.g. Tustin, 1990), a schizophrenic illness can develop when the controls of autism break down makes me think that there is something to be said for seeing autism as part of a psychotic continuum.] From being suicidal-as most autistics a r e - h e had become tnurderous. Bettelheim could no longer keep him in the school. He was sent to a state institution, where he was given a loboton~y.This account brought home to me that it is a serious matter to disturb the barrier of autism until, it1 psychoanalytic therapy, an 'infimtile transference' has begun to develop. This sets in train sociable ru~d friendly feelings towards people in the outside world. Even the murderous feelings are attached to real people and begin to lose their largerthan-life quality. Until these attachn~entsrein in the violence, the children are instinctively afraid that the violent feelings that are entrapped by the autism will be let loose. Work with autistic children highlights the importance of social relationships in human development. These provide constraints on violence and give protection. The stripping away of autistic processes by lnetllods that do not take account of the importance of early relationships must be a cause for concern. A ysycko-analytic trcatnzcnt A further relevant experience has been a weekly discussion

with a very experienced child psychotherapist about a threetimes-a-week psycho-analytic treatment of a non-speaking

6 AUTISTIC BARRIERS IN NEUROTIC PATIENTS autistic boy, who, since the age of thirteen, has been in psychotherapy for one year. The parents are co-operative and intelligent. They had sought psycho-analytic help for Denis (as I will call hirn), when he was much younger, but it was not available. He is not a classic Kanner-type autistic child. His early history was quite complicated. Just before he was born, his head was thought to be too small, with the possibility of tleurological disturbance. He screamed constatltly for the first three months of life and could not be comforted. He was a difficult baby to rear. He developed a considerable amount of l'mguage between the ages of one-and-a-half and three but stopped speaking following several traunlatic hospitalizations. He has been diagnosed as 'autistic' by several psychologists, with a score of 49 on the CARS scale. This corresponds to 'severe autism'. He hums persistently and displays characteristic stereotyped hand movements. About a year before he started treatment, he began to have fits (which were unsatisfactorily controlled by medication), but as treattilent has proceeded, these have become much less frequent. He seeins to use psycho-physical ways of dealing with his developmental difficulties. In trying to understand this boy, it has become clear to us that we are in the thick of his moral problem. In working with him, we seem to be studying the mainsprings of morality-that which Winnicott (1958) called 'the innate morality' of the child. This seems to stem from the fact that human beings are social herd animals. An i~nportantp,m of our understanding has been to realize the value of his autistic processes to this boy. We have come to see that Denis is desperately afraid of his vulnerability and his murderously violent impulses. The autism seems to provide a tough outer skil, bolh to protect his vulnerability and also to cage in his murderous violence. It is a defence against the 'black-hole' type of depression that is exemplified by John in Chapter 4. This means that it is a bllrrier against the disintegration 'md chaos threatened by the 'black hole', but it makes him resistant to our attempts to help him.

PREFACE

7

Denis expresses his violence in a 'low-key' way. For example, he pinches his therapist as he comes down the corridor to the therapy room. However, the terrible devil-grimaces he makes leave no doubt as to the intensity of his violence. As he enters the room, he bites and snaps at what he conceives to be the threats that have left traces behind them, such as smells, or at sensuous vestiges left on chairs, which he removes with scooping hand movements. He rubs his teeth with a toothbrushing motion as if to sharpen his fangs for an attack. Sometimes he is impelled to pace the room in a11 effort to master his feelings. However, he is never violent in a 'smashing-up' kind of way, although he will batter his own head very cruelly if not stopped. Ordinarily, he does not play with the toys that are put out for him to use, but recently, on one exciting day, he picked up the toy crocodile. He felt its hard skin and open mouth, which he put inside his own n~outli.He then tunled it over so that its soft vulnerable under-belly was exposed. After this, he sat on the couch, clutching a pillow. Then he wrapped himself in the blanket, so that only his head 'and a bit of the pillow were exposed. From experiences with other patients, I intuited that he could be feeling that the hard back protected the soft front. Dr Sydney Klein (1984), in describing 'an adult patient, gives us words for the feelings we have had about Denis when he writes: He gave me the impression of being covered by a leathery skin in which little flaps opened to take in interpretations which then disappeared without a trace 'and without any recognisable response. (p. 307) The 'crocodile session' was an occasion when one of the 'little flaps' opened in his tough autistic skin. We felt that, temporarily at least, Denis was less at the mercy of his violent feelings. By his use of a plaything, he had been able to clothe them in imagery, which enabled him to depict and communicate about them. Synlbolic play was beconling a possibility.

8

AUTISTIC BARRIERS IN NEUROTIC PATIENTS

However, our joy was short-lived. hi succeeding sessions he was closed up again. Perhaps he was afraid of having shown us his vulnerability? Most of the time, violent sensations seemed to rampage through muscle and vein to impel him to crude actions. His body was taut and tense as if to feel that in this way he could control these violent sensations. Feelings of weakness and helplessness make autistic children feel that they must be in control. As one sucli child said to me, 'I am the m'anager'. The autistic processes of 'autistic sensation objects' and 'autistic sensation shapes' (such as are described in this book) help them to feel that poign'ant violent sensations are blocked out. Realizing this function of the autistic processes has helped us to see it in a more positive light. We do not wait to batter it down. Rather, we want to niodify it and to help Denis to develop less crude ways of coping with the vulnerability and murderous violence that threaten him with sucli disintegration and chaos. Work with these children has made tile realize that sensations are the beginnings of psychic life. To paraphrase Freud, the 'body ego' is 'first mid foreniost' a 'sensation ego'. We have all used 'sensation objects' 'and 'sensation shapes'. It is when these beconie compulsive atid addictive, and are used inappropriately to tlie exclusion of more socialized ways of dealing with sensation-driven impulses, that they can be called 'autistic sensation objects' and 'autistic sensation shapes'. As a result, such children's sensation life has gone awry. It has become perverse. From time to time, Denis feels that lie spills, spits out, throws, or stares the violent sensations out of him to a corner of the room, where they form a shadow on tlie wall, of which he is then frightened (the beginnings of projection). At this stage tlie Jungian image of 'the shadow' seems a potent and pertinent one. It is formed from the stormy serisatioiis of his psycliotlierapy, tlie 'inviolent impulsions. In psycho~~nlytic fantile transference' focuses tliese teliipestuous feelings. Until

PREFACE

9

now, he had felt that there was no one to focus them and contain them adequately, nor to be aware of the content of his alarms. He had established no framework of relationships to help him to feel safe. Instead he made use of his autistic straitjacket. The beginnings of fantasy An import'ant difference between the violence of autistic children and that of mass murderers is that-as I mentioned earlier-autistic children do not have proper fantasies. It is a progress when they begin to do so. This has brought home to me that the time when autistic children begin to develop fantasies is a critical one. This progress needs to be dealt with by an experienced and insightful psychotherapist, who well understands the use of the 'infantile tr'ansference'. This mecans that the infantile trauma of awareness of separatedness can be reexperienced, and the powerful feelings associated with it can be felt in the presence of sonleone who u~lderstandsthem and who can help the child to come to tertns with them. All this is exemplified in Chapter 4. The working-over of this early situation towards the suckling mother is critical. It will affect the development of relationships and also the type of fantasies developed by the child. What I am trying to say is that the primary relationship ('bonding') needs to have become established before it is safe for the strict controls of autism to be modified. Otherwise the autistic child may become a murderer, like the child in the Orthogenic School, instead of confining himself to the murder of his own mind. An indication that basic infantile feelings associated with relationships are developing is that the child begins to miss the therapist when a separation occurs. The violence associated with this needs to be handled with p'uticularly insightful understanding. (It is pleasing that on two occasiol~sbefore a recent holiday separation, Denis put his arnls around his therapist's neck in an affectionate hug rather thul giving her the strangleholds he had inflicted on her previously.)

10 AUTISTIC BARRIERS IN NEUROTIC PATIENTS Brain damage and generic predisposition The forensic psychologists stated that predisposing factors for the personalities of tlie serial murderers included braindamage and a genetic tendency to violence. Some autistic children do have brahi damage, but in lily experience not all of them had been found to be brain-damaged by tlie methods of investigation available at the time. (I have only treated tlie ones where no brain damage had been detected). Altliougli organic factors were clearly important bi Denis's development, they cmnot by themselves account for his autism. Thus lie was able to produce a complete sentence at the age of six, tliough this was not repeated. Wliile in therapy, he showed himself to be capable of considerable humour, though this was sparingly expressed bi sign lmiguage. A genetic tendency towards violence in autistic children is more difficult to ascertain. The fact that not all babies who have had an unduly close relationship with a depressed mother develop autism makes one wonder if there is some genetic predisposition at work in those who do? It could be that different factors operate i i different children. Childhood Autism is a rwe syndrome tliat probably results from a rare combination of factors; the likelihood of their occurring together bebig somewhat remote. We should also remember tliat when a disturbance occurs in very early infancy, there is the temptation to ascribe it to genetic factors. Whether genetic factors are at work in sonie forms of autism is one of the i~nponderableswe have to live with. 'Psycl~ogerric'or 'psychobiologiccll'? Tliere is one more change in my thinking that needs to be mentioned. In the present book, as i i others, I have used the term 'psychogenic autism'. I did this to distinguish the type of autistic child in whom no serious brahi dnniage could be detected, from tlie type of autistic child in whom organic factors had been clearly shown to be present. However, a review by Charlotte Riley (1993) of the revised edition of A ~ ~ r i s r Sln/es ic in Children (1992) has sliown lile tliat tlie tern1 'psychogenic autism' is misleading. Riley writes:

PREFACE

11

The word 'psychogenic' becomes a red rag to the readers who espouse the current popular conviction that autism is a discrete diagnostic entity with entirely biological origins. She goes on to say that we cannot know with any certainty that a particular diagnosis is either psychological or biological in origin. She points out that the division of the human being into 'psychic' or 'somatic' is 'an artefact of our methods of study m d acadenlic disciplines. Quite rightly, Riley said that I have presented statements of the complexity of tlie interweaving of biological mid psychological factors in autisni. This has caused nle to revise niy termhiology. I now realize that a more accurate term would be 'psychobiological autism'. It would be helpful if readers of this book would bear this in mind when they come across the phrase 'psychogenic autism'. It will also become clear to the reader that throughout the book I no longer think of 'autisni' as the name of a specific discrete illness, but that, based on my findings from working with children who have full-blown autism, I see the name 'autism' as designating a specific set of processes that deaden awareness, and which niay be operating in other psychopathologies in which 'an elemental trauma with its attendant autistic reactions has been split off and has lain dorniant, to surface later hi life. I developed this theme further in a subsequent book, The Protective Shcll in Children and Adults, also published by Kaniac Books. [I wish to express my gratitude to Maria Rhode for help in org'mizing this preface.] FI-ancesTustin January 1994

12 AUTISTIC BARRIERS IN NEUROTIC PATIENTS REFERENCES Bowlby. J . (1944). 'Forty-four juvenile thieves: their characters and hotne life'. International Jorrrnal of Psyclro-Analysis, 25: 1-57 and 207-228 [republished as a ~nonogrnphby Bailliere, Tindall and Cox, London, 19461. Hobson, P. (1993). Autism and the Developnlent of Mind. Hove, Sussex, & Hillsdale, NJ: Lawrence Erlbaurli Associates. Klein, S. (1984). 'Delinquent perversion: problems of assirnilation: a clinical study'. Internutioncll Jorrrncll of Psyclro-Anc~lysis,65: 307. McDougall, J. (1986). Tl~cutrcsof tlie Mind. London. Free Association Books. McDougall, J. (1989). Tlteutres of t11e Botly. London. Free Association Books. Riley, C. (1993). Review of F. Tustin, Atitistic S t u t ~ sin Chitir.cn, revised edition (1992). Winnicott St~rtlics,8. Tustin, F. (1981). 'Psychologicnl birth and psychologicnl catastrophe'. In: J. S. Grotstein (Ed.), D o I Dare D i s t l ~ r bthe Uniiu~rsc? @p. 181-197). Caesura Press. [Reprinted London: Knrnnc Books, 1983.1 Also in F. Tustin, Alitistic Stutcs it? Chiltlrcw (revised edition) (pp. 96-1 00). London: Tnvistock/Routledge, 1992. Tustin, F. (1994). 'The perpetuation of an error'. Jotirnul of Cltild Psychotlzerupy: 20 (1). Tustin, F. (in press). Letter: 'A c o ~ n ~ n opsychoanalytic n error about the etiology of nutistic disorders of children'. .lorrrncll of tile Antrricun Psychounulytic Associcltion.

INTRODUCTION

In words, like weeds. I'll wrap me o'er. Like coarsest clothes against the cold; But that large grief which these enfold Is given in outline and no more. Tennyson, In Memoriuni, v

his collection of papers seeks to share insights derived from my work with autistic children whose autism seems to be primarily psychogenic in origin. These insights have shed light on a hidden part of certain has conneurotic patients-both adults ru~dchildren-which stituted a b'urier to their emotional ,and intellectual functioning. Thus, this book will be of wider clinical relevance than my two previous ones, which were mostly restricted to the study of psychogenic autistic childre~i.S o ~ n eof the papers have been published in various psychoanalytic and psychotherapeutic journals, but others have been written especially for this book. In a collection of papers some repetition is inevitable, but this should help to familiarize the reader with what may be an unfamiliar approach to the problem of getting in touch with certain hard-to-reach neurotic patients. Although the papers are concerned with a 'way-out' part of the personality, this does not mean that it is a 'way-out' book.

14 AUTISTIC BARRIERS IN NEUROTIC PATIENTS It represents an attenipt to get in touch with idiosylicratic preverbal states to try to bring them within tlie orbit of human communication. I have called upon poets and writers to help me in this task. It has seemed to me that we need to be encircled by their integrating aesthetic embrace as we go through the states of unintegration and disintegration that will be discussed in this book. The attempt has been made to use a kind of poetic science, hi tlie hope that it will hold both author and reader through states of hypervuhierability such as are experienced when the protective autism falls away. Thus although this will inevitably be a disturbing book, it is hoped that it will also be a therapeutic one. One more importmit point needs to be made. It has seemed to be niore useful to study in detail tlie disturbmice to the psyche encountered in psychogenic autism than to adjudicate 'blame', either to parents or children. In such a study, tlie attempt lias to be made to live inside the skin of ,an autistic child in order to feel what it is like to be there. There are limits to one's capacity to do this, but the fact tliat many mothers of autistic children have said tliat what I have written in my two earlier books on autism 'rings true' lias encouraged me to feel that I have managed to do this to soirle extent. With each book, I feel I have become more closely i11 touch with tlie nature of psychogenic autism. Thus, tliis book will be divided into two parts. The first part will deal with tlie nature of psychogenic autism, based mostly on my work with autistic children. Since tliis promises to throw light on the psychogenic autism encountered in adult neurotic patients, the second part of the book will deal with tlie capsule of autism encountered in such neurotic patients. In his paper, 'Autistic phenomena ui neurotic patients', drawing on his work with autistic children, Dr Sydney Klein has alerted us to the hidden autistic part of certain neurotic patients. He writes as follows: In tlie course of a periodic review of the progress of lily analytic practice, and particularly of my patients' habitual

INTRODUCTION

15

modes of communication, I became aware that certain among whom I thought of initially as being only mildly neurotic, some of whom were also 'analytic candidates, revealed during the course of treatment phenomena familiar in the treatment of autistic children. These patients were highly intelligent, hard-working, successful and even prominent professionally and socially, usually pleasant and likeable, who came to analysis either ostensibly for p,rofessional reasons or because of a failure to maintain a satisfactory relationship with a husband or wife. It gradually became clear that in spite of the analysis apparently moving, the regular production of dreams, 'and reports of progress, there was a part of the patient's personality with which I was not in touch. I had the impression that no real fundamental changes were taking place. (S. Klein, 1980, p. 395) I have quoted at length from the introduction to Sydney Klein's paper because it describes so well the encapsulated, well-nigh impenetrable, autistic part of the personality of those neurotic patients who seem as though they will never be ready to finish coming to analysis because a crucial empty part of them has never been reached. Some readers may have difficulties in accepting the thesis that neurotic patients can have autistic impediments. This nlay be because they have never worked with psychogenic autistic children, 'and thus find it difficult to accept that such odd children can have 'an affinity with people with whom they can more easily identify. However, those of us who work with such children find an answering echo in ourselves. Other readers, p6uticularly those with a psychiatric orientation, may have difficulties in accepting this thesis because they think of autism as an irreversible, discrete syndrome, which is often associated with brain lesions and always with mi inbuilt cognitive defect. This has not been my experience. Sotile autistic children are undoubtedly brain-damaged. But there are other children whose autism seenls to be psychogenic in origin. It is

16 AUTISTIC BARRIERS IN NEUROTIC PATIENTS

these latter children who have been the source of inspiration for the findings in this book. It will become clear that, as I have worked with these children, my understandings have been in a continual process of evolution. Chapter 2 traces the growth of this understanding. Frances Tustin

March 1986

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'

o 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 psychoanalytically 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, psycho-

20 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S analysts 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 neurophysiological 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. T h e 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. T h e 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

THE NATURE OF PSYCHOGENIC AUTISM

21

imagination (see Frith, 1985). These children have no inner life. T o 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 consultingroom. 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

22 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S 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, thkir 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 'notme', 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

THE NATURE OF PSYCHOGENIC AUTISM

23

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. T h e same loss of the mother a few months later would be a loss of object without this added loss of part of the subject. I n 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. I n 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.

24 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S 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.

T H E N A T U R E OF P S Y C H O G E N I C .4UTISM

25

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

26 AUTISTIC BARRIERS IN NEUROTIC PATIENTS which have outlived their usefulness, become autistic barriers to cognitive and affective functioning. T h e effort to keep going and to maintain an appearance of nornlality 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. T h e Fall and its accompanin~entstend 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. T h e 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

T H E N A T U R E OF PSYCHOGENIC A U T I S M

27

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.

Thefindings 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). T h e behaviourists write of autistic children's incapacity 'to encode and process information'. They see this as arising from an 'innate cognitive defect'. Acquired cognitiz~eand emotional defects This chapter has indicated that cignitive 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. T h e 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 shocks. These bring about a state of diminished perception which leads to diminished thinking and feeling. T h e autistic child, and the autistic part of a neurotic patient, is numb and dumb. They

28 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S seem to be in a state of suspended animation similar to that of the babies in the Mexican earthquake in 1985 who were found alive after many days of being buried by the rubble. T o use this as a metaphor: as therapists with such patients, we have to tunnel through the rubble to reach them. Having reached them we need to give them all the psychic resuscitation and healing that growing insight makes available to us. But this is a sensitive and delicate task, and we need to be well in touch with, and to understand the detail of, their autistic experiences. This book is an attempt to do this. When the psychic mishap of seemingly irretrievable loss first occurred, these autistic reactions were appropriate and necessary. But over the years they have become impediments to psychic functioning. T h e only way that the autism can be modified is by interaction with life and by a more spontaneous use of their own inbuilt capacities. Many of the chapters in this book are concerned with how we can help our patients to begin to do this. T h e emphasis in this type of psychotherapy is not on attempting to make up for what we infer may have been the deficiencies of their infancy. (After all we were not there and we cannot be sure about this.) T h e emphasis is on helping them to go through primitive processes of mourning, which will heal the wound of their too-early sense of loss, and relax the tensions associated with the trauma, so that they can begin to use the capacities with which they are usually well endowed. This is a very realistic and unsentimental procedure. I n some psychoanalytic formulations, the mother seems to be held to be totally responsible for her child's psychogenic autism. It is as if the child is viewed as a lump of clay to be moulded, instead of the bit of dynamite the human baby is. As well as distorting our views on aetiology, such an approach distorts our views on psychotherapy. T h e patients' natural, inbuilt propensities for growth, healing and creativity are not given sufficient weight in attempts to free them from their autistic impediments. Recognition of these biological 'givens' immediately promotes a more hopeful approach to therapeutic

29 endeavours. Instead of trying to compensate our patients for what we think they may have lacked, we try to free them, with stern but compassionate understanding, from their autistic practices so that they can begin to use the abilities they have, often in very good measure. T o do this, they need to feel that we believe in their capacity to do so. Thus, it is implicit throughout this book that the patients' own nature and their capacity for response, as well as external nurturing circumstances, will have played their part in psychogenetically induced autistic pathology, whether it is well nigh total as in the autistic child, or partial as in certain neurotic patients. T H E N A T U R E OF PSYCHOGENIC AUTISM

The importance of early suckling experiences In order to understand such patients, it is necessary to be in touch with the nature of the infant's early suckling experiences. This is where relationships begin. Clinical work indicates that the sensation of nipple-in-mouth (or teat of the bottle experienced in terms of an inbuilt gestalt of the breast) is the focus for the development of the psyche. Associated with the mother's encircling arms, her shining eyes and the mutual concentration of their attention, it becomes the core of the self. It becomes associated with regulation, with bearing the suspense of waiting, with tolerating human limitations, with boundaries and with the sorting out of sensations. T h e way in which the 'breast' is given and the way in which it is taken leaves a mark for good or ill on the developing psyche. This will be affected by the child's responses and by the quality of the mother's relationship to the infant's father, and by the circumstances of the parents' own infancy. In normal development, the heightened degree of responsiveness and the especial quality of attention of both the suckling mother and her infant partake of the sublime, and even of the 'mystical'. It is a physically based psychic experience. This empathic communion is the earliest form of communication. It fosters the growth of the psyche. Patients who are prone to autistic ways of behaving have had this early state

30 AUTISTIC BARRIERS IN NEUROTIC PATIENTS of communion traumatically disturbed. This means that, instead of a psychic core which holds them together, they have an unmourned sense of loss - a 'black hole with a nasty prick', as John, who is discussed in Chapter 4, so graphically described it.

Remedying the 'black hole' This 'black hole' cannot be filled by 'autistic objects' nor glossed over by 'autistic shapes'. (Autistic objects and autistic shapes will be discussed in later chapters.) It can only be healed by cooperative activities with people and creative activities with the outside world. These stimulate the biological 'givens' for psychic growth and healing. States of autism prevent these 'givens' from being recognized, because such patients are afraid of anything which cannot be brought under their tyrannical control. These 'givens' are unseen and mysterious. When they come into play, they are much more powerful for influencing the way in which we live our lives than are our puny efforts at controlling what happens to us. They work within us without our doing anything about it. T h e effectiveness of psychotherapy depends upon their release. We never really know how it happens. But we find that as patients in an autistic state gradually work over their experience of separateness, and begin to relate to human beings who are experienced as separate and different from themselves, they become able to let unseen, intangible forces which are beyond their control begin to work within them. Hope and trust start to develop. This means that there is the basis for reality-based beliefs about themselves and about the outside world. I n short, inbuilt impulsions come into play which have previously been blocked.

ilfod$ying the autism But before this can be achieved the autistic blockage has to be modified. In an autistic state, patients are not in touch with their own humanity, nor that of other people. In this state they cannot make the abstractions needed for imagination and

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31

empathy. They are stuck in a sensation-dominated, overconcretized mode of functioning. This is a great stumblingblock to psychoanalytic work. In such states, these patients are suffering from a miscarriage of motivation. They have turned away from commonly agreed reality. Instead of attending to the life-enhancing possibilities that are available to them, both within themselves and in the outside world, their attention has become fixated upon autochthonous (self-generated) sensation objects and shapes. These patients are creative and resourceful, but these gifts have gone in a sterile direction because they have generated artefacts which were unshared and unshareable. Our task is to help them to turn from these automatic, idiosyncratic ways of behaving and to begin to tolerate the sadness and the frustrations, and to enjoy the delights of deep, interactive relationships with other people. These patients cannot be bullied or coaxed out of their simplistic, isolating modes of behaviour. These will only be modified as their need for them is understood, and they experience being held in a warm, firm, sane, caring, disciplined and disciplining relationship which gets in touch with the part of them that has been left to go its own whimsical and eccentric way. As they experience this, the psychic mishaps of their infancy begin to be healed. This occurs through the medium of the infantile transference, in which they repeat the situation of tragic disillusionment. We need to be aware of this form of transference and to have some understanding of it, if we are to get in touch with autistic states and to modify them. Thus, neurotic patients can be relieved of their fear of a breakdown which has already occurred (see Winnicott, 1974). T h e healing and disciplining type of psychotherapy needed by patients with such an injured psyche will be discussed in Chapter 16. It has seemed to me that in enlightening us about the idiosyncratic, restricted world in which they live, autistic children enable us to get in touch in a realistic and meaningful way with neurotic patients who have an immobilized, frozen part of their personality. They demonstrate for us the autistic

32 AUTISTIC BARRIERS IN NEUROTIC PATIENTS operation of pre-image, preverbal, preconceptual ways of behaving. They show us that this behaviour has inhibited their use of their capacities and caused them to feel excessively insecure and underconfident.

CHAPTER TWO

The growth of understanding : a personal statement Nobody can tell you how you are to live your life, Or what you are to think, Or what language you are to speak, Therefore, it is absolutely essential that the individual analyst should forge for himself the language which he knows, Which he knows how to use, and the value of which he knows.

W.R.Bion, 'Evidence'

his chapter is a much revised version of a paper which was written for the French psychoanalytic journal Patio (1984) 3 :109-21. Originally, the paper was for an issue which was to be devoted to innovations in psychoanalysis. The editor asked me for an interview-article to describe the growth of my thinking with regard to the psychoanalytic treatment of psychogenic autistic children. Thus, the paper was the story of how I came to be involved with these children and was driven to try to understand them. Dr Peter Medawar, the well-known British research scientist, whose sayings I shall quote from time to time in this chapter, has rightly stressed the part that luck and opportunity play in making new discoveries, however small these may be (Medawar, 1979). This chapter will be an account of the many privileges I have had which encouraged me to embark on the difficult task of trying to get in touch with these seemingly

34 AUTISTIC BARRIERS IN NEUROTIC PATIENTS

inaccessible children. Dr Medawar quotes Fontanelle, who said, 'Ces hasards ne sont que pour ceux quijoient bien!' ('These strokes of good fortune are only for those who play well.') But to 'play well' we have to remember the words of Pasteur, who said, 'Fortune favours the prepared mind.' Thus, this contribution must acknowledge the many people who have shed light upon my path and helped to prepare my mind for the daunting task of entering the mind of an autistic child in such a way that changes in his view of the world could be initiated. Preparation for the task Firstly, I have been helped and supported by being married to a physical scientist who, in his own speciality, has been an innovator. (In his war work on automatic control, he pioneered the early formulations for what is now called systems theory or cybernetics.) My personal analysis with Dr W.R. Bion also brought me into contact with an original mind. In addition, in my training as a child psychotherapist at the Tavistock Clinic in London, I had the great good fortune to have as my teachers Dr Esther Bick and Dr John Bowlby, both of whom, from their different points of view, impressed upon their students the value of detailed observations and the importance of specific rather than general formulations. Supervision from Dr Herbert Rosenfeld and D r Donald Meltzer was also a very important preparation. Having finished my training at the Tavistock Clinic, I was fortunate in that I accompanied my husband to the United States for a year in 1954 and, on Dr Bowlby's advice, went to work at the Putnam Children's Center in Boston, Massachusetts. At that time this was a research and treatment centre for young 'atypical' children (as they called them), amongst whom were a number of autistic children whose disturbance seemed to be mainly psychogenic rather than organic in origin. Here, as well as working as a psychotherapist, I went to look after some of the autistic children in their own homes. I was very moved by the tragedy to the parents of these

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unresponsive children, and felt very strongly that I wanted to see if something could be done so that they became more accessible. I was again fortunate when I returned to England in that Dr Mildred Creak, who was very knowledgeable about childhood psychosis and also a superb diagnostician in this field, sent me several autistic children as private patients. Eventually I went to work with her at Great Ormond Street Children's Hospital in London. Of course, all these possibilities would have passed me by, had it not been that my own temperament and pathology made me interested in shy, inhibited children. Also, I had always had a tendency to study the basic aspects of a subject, one of my early pieces of work being a study of 'Plant movements and tropisms'. Thus, the privileges, the good fortune, the prepared mind, the motivation and the opportunities were all there. What was needed now was a capacity for patience and hard work. I had always been persevering and this stood me in good stead. So, after the first twenty years of working with psychogenic autistic children, and as a result of a profound disturbance in my own emotional life from which I learned a great deal about the roots of phobic inhibition, I was driven to write my first book, Autism a n d Childhood Psychosis. This was written as the result of great emotional pressure from within myself. The second, Autistic States in Children, written ten years later, was a less emotionally-charged book and was the result of lectures I had given, on yearly visits over a period of five years, in Rome University's Institute of Childhood Neuropsychiatry. Here there is a special unit for the psychoanalytic treatment of both autistic and schizophrenic-type children, under the unflagging and humane care of Professor Adriano Giannotti, with Professor Giovanni Bollea in overall charge of the Institute. In the early days of the unit the two senior psychotherapists, Dr Guilianna De Astis and Eleonora Ft D'Ostiani, flew over to England separately each month, over a period of two years, to discuss every single child they had in treatment. Thus I could see psychotherapeutic work being carried on in a unit which

36 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S had far more resources than I had had in private practice; the parental relationship and the mother-child couple, in particular, could be studied much more fully than I had been able to do. I have found the scientific rigour and orderliness of the Kleinian psychoanalytic technique to be very suitable for the treatment of autistic children. However, since Melanie Klein's findings were drawn from schizophrenic-type chilren, it was inevitable that work with autistic children would generate new insights. The only autistic child seen by Mrs Klein was the boy called Dick whom she describes in her paper, 'The importance of symbol formation in the development of the ego' (see next chapter). Mrs Klein was writing in 1930, fourteen years prior to Kanner's differential diagnosis of early infantile autism. Although she anticipated many of Kanner's findings, she was naturally perplexed about the diagnosis of Dick's condition. Reluctantly and after much uncertainty, she finally interpreted Dick's psychopathology in terms of the schizophrenic-type children she had previously studied. Melanie Klein has given us a great legacy, but it does both her work, and the cause of scientific enquiry, a grave disservice if we blindly apply her insights to autistic states for which they are not appropriate, at least in the early stages of treatment. I had to learn this after many heart-searching9 as to whether I was being treacherous to someone to whom I owed so much. But John, the four-year-old autistic boy whom I have already mentioned, taught me about the 'black hole with the nasty prick' (Tustin, 1972) which I also became aware of in myself. This made me realize that there were even earlier states than those described so courageously by Melanie Klein. I then found that Michael Balint (1968), Winnicott (1958) and Mahler (1961) had described the phenomenon of the 'black hole', though in other terms: Balint's 'basic fault', Winnicott's 'psychotic depression', Mahler's 'loss and restoration of the symbiotic love object'. Following Mahlerl and also James Anthony whose classic

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paper on autism broke new ground (Anthony, 1958), 1began to use the term 'autistic' for the earliest state of normal infantile development, as well as for pathological states. T o use the term 'autism' in this way was appropriate at the time when Mahler and Anthony were writing, but since then the word 'autism', as first used by Bleuler in 1913 in terms of its etymology, has become so contaminated with pathological associations that it can no longer be usefully used for normal states. For example, if we use the adjective 'autistic' for early infantile states, it gives the impression that such states are being viewed as inactive and passive, instead of the aware, questing states they obviously are. Thus I have come to use the term 'auto-sensuous' for the earliest states of normal infancy, and autism for pathological ones. This will be discussed more fully later. At this point, let me discuss the understandings I have found to be mutative in psychotherapy with autistic states. Mutative understandings My particular contribution to understanding psychogenic autistic children has been to realize the tactile, sensationdominated nature of their world, and to highlight the way in which what I have called 'autistic objects' and 'autistic shapes' (described later in this book) have impeded such children's cognitive and emotional functioning, as also their sense of identity and relationships with people. These findings from work with autistic children have made very meaningful to me certain passages of Dr Peter Medawar's Advice to a Young Scientist, where scientific methods and discoveries are discussed. Even though Medawar is mainly writing about the biological sciences, what he says has much relevance to psychological investigations. For example, in writing about Thomas Kuhn's two books, The Structure of Scientific Revolutions and Essential Tension, Medawar says : 'The "essential tensionJ' to which Kuhn refers in the title of his latest book is between our inheritance of doctrine and dogma as they affect science and the occasional upheavals

38 AUTISTIC BARRIERS IN NEUROTIC PATIENTS that inaugurate a new "paradigm" ...' (p.92). Medawar sees scientific exploration as a dialogue 'between two voices, the one imaginative and the other critical, between conjecture and refutation, as Popper has it' (p.85). (In my case, my husband has often supplied the 'critical voice'!) Later, Medawar says: '. scientific research, like other forms of exploration is, after all, a cybernetic - a steering process, a means by which we find our way about, and try to make sense of a bewildering and complex world' (p.86). In the case of autistic children we have to try to 'make sense' of a 'bewildering' elemental 'world', haunted by primeval forces. In studying this world we can again draw guidance from Dr Medawar when he says: 'Heroic feats of intellection are seldom needed. "The scientific method", as it is sometimes called, is a potentiation of common sense' (p.86). The need for common sense was never more urgent than in studying the world of the psychogenic autistic child. We do not need esoteric theories, but we do need to train ourselves not to disregard the obvious. I also think that at the beginning of our work we should not confuse ourselves with tpo much reading of what other people have said. Some papers seem to be like a Tower of Babel amongst which the writer's own voice is lost. Fortunately, the Tavistock child psychotherapy training was a somewhat cloistered affair in which we digested Freud and Klein, with Dr Bowlby introducing us to ethology and researches in child development (Dr Bowlby's critical voice keeping the balance alongside Mrs Bick's imaginative one). The Kleinian psychotherapeutic technique, with its simplicity and its emphasis on the dynamic transforming influence of the infantile transference, is a very good instrument for studying what is going on in the psyche of the child. It is as if we put the child's psyche under our mental and empathic microscope to study it in detail. So long as we have not developed 'tunnel vision', we do not see only Kleinian phenomena. From this secure base of sound training in observation and

..

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psychotherapeutic technique, the work with autistic children gradually led me to the writings of other psychoanalytic workers who were not members of the Kleinian school in which I had been trained. This happened in the following way. When I wrote my first paper on autism in 1966, in which I described John's revelations about the 'black hole', it was an eye-opener to me when I was told by a colleague that Winnicott, in a paper entitled 'The mentally ill in your case load', as long ago as 1958, had mentioned in passing this very early type of depression which occurs when the loss of the mother is experienced as the loss of part of the body (Winnicott, 1958). I also learned that Margaret Mahler had written a paper about this with reference to childhood autism (Mahler, 1961). Similarly, after I had finished my first paper on autistic shapes, and after it had been accepted for publication, I heard a paper given by Dr Piera Aulangier of Paris who, from her long experience with schizophrenic adult patients, described what she called 'tactile hallucinations' (Aulangier, 1985). She distinguished these from the usual type of schizophrenic hallucinations. From her description of them they sounded very like the tactile autistic shapes I had learned about from the autistic children; indeed in a paper published in the International Review of Psycho-Analysis in 1984, I had said that these autistic shapes seemed to be a kind of 'tactile hallucination' (see Chapter 7). I also found that Michael Fordham (1976) had coined the term 'self-object', and that Winnicott had used the term 'subjective object' (Winnicott, 1958), for similar phenomena. (However, although the self-object and the subjective object have certain features in common with autistic objects, I have found it necessary to distinguish between normal and pathological manifestations. Normal auto-sensuous objects are sucked and are such things as the finger, the fist, the knobs on the cot, a piece of shawl, etc. They are associated with a developing sense of self. Autistic objects are pathological. They are not sucked but are hard objects which are clutched. They

40 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S

are associated with states in which there is no sense of being a self .) I found these separate confirmations from various sources unconnected with each other, and with a different orientation from my own, very reassuring, in that they indicated that my findings were not idiosyncratic to me alone. You will remember that Spitz has said that such confirmation is the only validation we can have in psychoanalytic investigations. Schizophrenictype children (or 'confusional entangled' children, as I call them) are very open and tell us about their strange misconceptions quite clearly. The encapsulated autistic children are very different in that they are closed up and secretive. It is difficult to feel sure about what one has inferred, so confirmation of one's insights is very necessary. The fact that I was not the first in the field was outweighed by the relief that other workers had seen what I had seen, though in different contexts. As Medawar so picturesquely exprdsses it, the growth of scientific ideas 'is not at all like cooks elbowing each other from the pot of broth'. Usually, in developing new understandings, unbeknown to ourselves, we are developing ideas which are 'in the air' and waiting to be developed further; to continue with Medawar's image, 'the broth' is waiting to be stirred by experienced cooks (1979, p. 33). My job has been that of a synthesizer and harmonizer. I have been able to relate the phenomenon of the 'black hole' to autistic objects and to autistic shapes, as part of the pathological network which we call psychogenic autism. These phenomena have been integrated into a scheme of understanding which helps us to enter the encapsulated states of autistic children, and the capsule of autism of neurotic patients, in a tactful, sensitive, mutative way so that more normal psychological functioning can be facilitated. As well as learning from my patients I have, of course, learned a great deal from the psychotherapists and psychoanalysts who have discussed their clinical work with me. I

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would like to mention all these people by name, but this is not possible. As an illustration of the enlargement of my understanding from such a source, I will quote a recently published paper by Mrs Sheila Spensley, a psychoanalytic psychotherapist who discusses her work with me from time to time. The paper was called 'Mentally ill or mentally handicapped? A longitudinal study of a severe learning disorder' (1985b). In this paper Mrs Spensley recounts the sad story of A, a twenty-seven-year-old young woman who, as the result of a misdiagnosis when she was seven years of age, had been constantly moved back and forth from psychiatric hospital to mental subnormality units, none of which had been appropriate or helpful. Finally, by great good fortune, she was seen by Mrs Spensley, who had treated psychogenic autistic children. T o everyone's surprise and dubious incredulity, Mrs Spensley suggested individual psychotherapy for A. In the summary of her paper Mrs Spensley writes of this patient as follows: 'Psychotherapy has disclosed a significant component of autism in the personality which is resorted to regularly and which seems to drag the patient into a passive acceptance of half-life which she tries not to mind.' Mrs Spensley also says: In the course of some eighteen months of psychoanalytic psychotherapy, this young woman of twenty-seven, once deemed brain-damaged at the age of seven years, has shown herself capable of sustaining once-weekly psychotherapy. Against all expectations she has taken responsibility for her own attendance, travelling by public transport alone to her sessions. She has also taken initiatives in relation to finding work for herself.

I should also add that she has been able to live amicably at home with her parents, who had previously found her impossible. Mrs Spensley's report of this patient has made me realize the value of the understandings derived from clinical work with

42 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S psychogenic autism, in making our diagnoses more precise, so that fewer patients waste their time in inappropriate placements and in receiving inappropriate treatments. I have also been greatly helped by the constructive criticism of some of my British colleagues. They have helped me to see where I had not made myself clear in Autistic States in Children, and also where I needed to modify certain of my suggestions about early infantile development. Again, as Medawar so well expresses it, 'A senior scientist is much more flattered, by finding that his views are the subject of serious criticism than by sycophantic and sometimes obviously sim.ulated respect' (p. 55). (In this connection I want to thank Anne Alvarez who, in the midst of a busy programme, found time to enter into a discussion with me by means of an interchange of letters.) Such constructive criticism, and further evidence, have meant that the thinking embodied in my two books on autism has been in a constant state of revision. As Medawar says: 'As for revolutions, they are constantly in progress: a scientist does not hold exactly the same opinions about his research from one day to the next, for reading, reflection and discussions with colleagues cause a change of emphasis here and there and possibly even a radical appraisal of his way of thinking' (p. 93).

Clanjkation and revision of previous views Let me now outline some of the clarifications and revisions of my views which have occurred since writing Autistic States in Children. As mentioned earlier in this chapter, one of these revisions has been to use the term auto-sensuous for normal early infantile developments, and to reserve the term autistic for pathological ones. Making this distinction has thrown light for me on the current psychoanalytic controversies concerning awareness of bodily separateness in early infancy. I should like to discuss this. The work of observers such as Trevarthen (1979), Tom Bower (1977) and Brazelton (1969) implies that when early

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differentiations are proceeding normally, there are likely to be flickering moments of awareness of bodily separateness from the mother even from the very beginning of life. Also, arising from their work with autistic children, De Astis and Giannotti have suggested that, in normal development, the caesura of birth is healed by responsive interactions between mother and baby (De Astis and Giannotti, 1980). They have shown - and my own work confirms this that in autistic children this healing has not occurred. In my experience, every subsequent awareness of bodily separateness from the mother reactivates the unhealed primary wound of bodily separateness. Psychotherapy heals this 'wound', which in autistic children is often experienced as a 'hole' because, for them, bodily separateness from the mother has been experienced as a traumatic breaking away from an inanimate 'thing', rather than as a gradual process of differentiation from an alive human being. One reason for this traumatic breaking away is that the mother of an autistic child has often been depressed and unresponsive in the child's early infancy. She may have experienced the child in her womb as a comfort for her sense of inner loneliness. In such a situation, when the infant is born, the mother feels that she has lost a reassuring part of her body. The baby also seems prone to this elemental 'black hole' type of depression. (This will be discussed more fully in Chapter 4, and should become clearer to any reader who may be having difficulties in understanding it.) In this state, the need for a continuous tangible bodily presence is very intense, as also the disappointment that this is not possible. I would suggest that in normal early infantile development, there is an awareness of separateness which is made bearable by auto-sensuous activities such as sucking and bodily interactions with other people, particularly with the mother. But, in pathological autistic development, as, the result of the lack of responsive interactions, any awareness of bodily separateness, however slight, has been unbearable. It has provoked an agony of consciousness. This painful awareness has been muted, and

-

44

AUTISTIC BARRIERS IN NEUROTIC PATIENTS

restricted by the use of autistic objects and autistic shapes. These autistic manipulations and stereotypes replace the normal responsive interactions between mother and baby, and prevent normal differentiations and integrations from taking place. It has seemed to me that merging with the mother, who is experienced as an inanimate part of the subject's own body, is apathological reaction which is both sought and feared. Further thought on work with psychogenic autistic children has also enabled me to make another clarification. At least to my own satisfaction, I have become able to distinguish more clearly between the 'ego' and the 'self'. Early ego activities would seem to arise, in the first place, from the neuromental system. At first, the newborn infant who is lacking in experience of the outside world can only react in terms of inbuilt neuromental propensities which become expressed through auto-sensuous activities. The early ego is an auto-sensuous ego. This view is consonant with Freud's statement that 'the ego is first and foremost a body ego' (Freud, 1923, p.26). In normal development, increasing experience of the outside world facilitates the maturation and sophistication of this elemental ego. But the traumatized autistic child shuts out experience of the outside world. Thus, his ego development is morbidly fixated at an uncouth, crude bodily level of precocious, overconcretized and hypertrophied reactions. This leads to the sense of having a swollen empty shell fabricated from the subject's own bodily activities. This is a barrier to intercourse with the outside world. Patients in encapsulated autistic states also lack a sense of self and of individual identity. This is because the sense of self and of individual identity is dependent upon relationships with other people. Autistic children are averted from such relationships, and so they have no sense of self. Thus, I have come to realize that I was incorrect in attributing to psychogenic autistic children a 'false self' as described by Winnicott (1960). I have also come to realize that states of autism are not narcissistic. This is because a sense of self is

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obviously a prerequisite for the development of narcissism. Schizophrenic-type patients and neglected children have developed relationships with people, albeit these are fragile and disturbed. Thus they can be said to have a 'false self' and to be narcissistic. The psychogenic autistic child, and neurotic patients in an autistic state, avoid human relationships. Thus they are empty of a sense of self, and cannot be said to have a 'false self' or to be narcissistic. (As early as 1963 Enid Balint described such an empty state in a paper called 'On being empty of oneself'.) For these reasons I agree with Dr Sydney Klein who, in describing neurotic patients who manifested autistic phenomena, writes about them in the following way:

.

There is an obvious parallel with what Winnicott.. has called 'the false self', and which Rosenfeld (1978) has termed 'psychotic islands' in the personality, but I do not think these terms quite do justice to what may be described as an almost impenetrable cystic encapsulation. ..which cuts the patient off from both the rest of his personality and the analyst. (Klein, S., 1980)

I suggest that the 'impenetrable cystic encapsulation' is the expression of a hypertrophied, crude body 'ego' which had been startled into precocious development along an aberrant path by the impingement of unbuffered awareness of bodily separateness from the mother. This puffed-up ego is not a 'true' ego formed by bearable contact with the outside world, It is both a deceit and a conceit. Lacking object relations, and thus being empty of a sense of self, the psychogenic autistic patient can best be described as having an ego which is an 'empty fake' or a 'hollow sham'. He does not have a 'self' to be 'false'. Another revision I have made in my thinking is that I have come to realize that psychogenic autism is a defence against the confusion and entanglement of pyschosis, rather than psychosis itself. It seems more accurate to see it as a gross arrest of mental and emotional development. When the autism is lifted, a

46 AUTISTIC BARRIERS IN NEUROTIC PATIENTS vulnerable, clinging, confused, helpless child is revealed who may become psychotic unless we realize his need for safety and protection, and can provide it for him by our understanding. The autism has been a protection for this hapless creature. It is a serious responsibility to deprive such patients of their autistic protections. We need to be able to help them to develop something better to replace them. The more accurately we understand the& patients, the greater will be the possibility that they will develop 'basic trust in other people, and confidence in themselves. These are very necessary developments, since the autistic encapsulation means that they have been cut off from the outside world, and so are liable to a psychotic breakdown. Michael Faraday, that great pioneer in the field of electrical phenomena, defined innovation as 'finding the "go" of things'. With the help of the children, their concerned parents, and friendly professional colleagues, I have come to understand a little of the 'go' of autistic development. There is much that remains to be understood. But the insights outlined in this paper, and those of other psychodynamic workers, have enabled us to enter the psychogenic autistic children's world in a therapeutic way so that they could begin to respond to other people and become aware of the outside world. Thus, they are glad to be 'born', both physically and psychologically. Let me end by a quotation from Dr Medawar, whose sayings have illuminated this paper. He writes: 'Those with enough hopefulness in their make-up willingly go along with the belief that ... the pursuit [of understanding] is truly via lucis, the way of light' (p. 106). An alternative title to this paper could have been 'The dawning of enlightenment'. It has been a slow dawn, but the efforts of dedicated workers, some of whom are mentioned in the references, are ensuring that this crepuscular light will be increased, so that more patients who are entrapped by autistic reactions can be helped to normal functioning. But it requires professional workers who do not impose theoretical con-

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structions, evolved for other psychopathologies, upon such patients' behaviour. We need to realize that these patients are different from any other patients that we see, because they have not developed relationships. .Also, in the growth of understanding, we are always trying to evolve language which is a closer fit to the phenomena we are observing. I hope that this will take place as the book proceeds.

CHAPTER THREE

Thoughts on psychogenic autism with special reference to a paper by Melanie Klein 'There was, on his side, no affective tie to people. He behaved as if people as such did not matter or even exist. It made no difference whether one spoke to him in a friendly or harsh way. He never looked at people's faces. When he had any dealings with persons at all, he treated them or rather parts of them, as if they were objects.' Paul, aged five years, described in Leo Kanner's original paper on autistic disturbances of affective contact (1943, p. 217)

his revised paper was originally published in the Journal of Child Psychotherapy (1983) 9 :119-3 1, and discussed a paper by Meianie Klein entitled 'The importance of symbol formation in the development of the ego' (1930a). She described her analysis of a four-year-old boy whom she called Dick, and whom we would now recognize to be autistic. I sought to discuss Mrs Klein's paper from the point of view of autistic pathology.

T

Mrs Klein's paper When Mrs Klein wrote her paper in 1930, Leo Kanner's classic paper differentiating the syndrome he called 'early infantile autism' from mental deficiency had not been written. We had to wait until 1943 for his findings to be available to us. It is a mark of Melanie Klein's originality and perspicacity that in her paper she anticipated many of Kanner's findings. For example, of

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Dick's case she wrote: 'many cases of this sort are classified as ... mental deficiency' (1930a, p.230). Also, compare Mrs Klein's description of Dick with the extract from Leo Kanner's description of Paul which headed this chapter. Mrs Klein wrote : This child, Dick, was largely devoid of affects, and he was indifferent to the presence or absence of his mother or nurse. From the beginning he had only rarely displayed anxiety, and that in an abnormally small degree .. He had almost no interests, did not play, and had no contact with his environment. For the most part he simply strung sounds together in a meaningless way, and constantly repeated certain noises. When he did speak he generally used his meagre vocabulary incorrectly. But it was not only that he was unable to make himself intelligible; he had no wish to do so. More than that, Dick's mother could at times clearly sense in the boy a strong negative attitude which expressed itself in the fact that he often did the very opposite of what was expected of him .... When he was hurt, he displayed very considerable insensitivity to pain, and felt nothing of the desire, so universal with little children, to be comforted and petted ... he also ran round me, just as if I were a piece of furniture ... (1930a, pp.221,222)

.

As an infant, Dick had had great difficulty in sueking. Klein describes how his mother tried to breastfeed him, but he would not suck and nearly died of starvation (p.222). I have found early difficulties in sucking to be characteristic of all the autistic children I have seen, and also of those cases I have supervised. Dick's weaning difficulties were also characteristic of autistic children. Klein reports: 'When the time came for him to have more solid food, he refused to bite it up and absolutely rejected everything that was not the consistency of pap' (p.223). Time and again, the parents of an autistic child have told me such things as 'he will only eat soft food and rejects hard lumps' or that 'he will only accept semi-liquid food'. Thus, if Dick were

50 A U T I S T I C BARRIERS IN NEUROTIC PATIENTS seen now he would certainly be diagnosed as autistic, his autism being seen to be akin to that described by Kanner. This Kanner-type autism needs to be distinguished from the autism which arises from disorderly rearing practices, or from detectable brain damage, or from hospitalization or surgical intervention in early infancy, or other interruptions to early ongoing infantile development. Since he had made some developments before coming to see Mrs Klein, Dick would be likely to be assessed as having a hopeful prognosis. For example, he had become toilet-trained and he used a few words appropriately. H e also responded very quickly to Mrs Klein's unique ability to be in therapeutic touch with a withdrawn and frightened child, even though this fear was not shown openly. Mrs Klein herself writes: 'The fact ... that analysis made it possible to establish contact with Dick's mind and brought about some advance in so comparatively short a time suggests the possibility that there had already been some latent development as well as the slight development outwardly manifest' (p.231). She goes on to say: 'But, even if we suppose this, the total development was so abnormally meagre that the hypothesis of a regression from a stage already successfully reached will hardly meet the case' (p.231). She says this because she was puzzled about the diagnosis of Dick's condition, Leo Kanner's paper not being available to her. She realized that Dick was different from the schizophrenic children she had analysed. She writes: 'Against the diagnosis of dementia praecox is the fact that the essential feature of Dick's case was an inhibition in development and not a regression' (p.230, my italics). However, she finally decided that Dick's illness was a variant of schizophrenia, although she obviously felt uneasy about this diagnosis, because later in the paper she wrote about Dick's illness as follows: 'It is true that it differs from the typical schizophrenia of childhood in that in him the.trouble was an inhibition in development, whereas in most such cases there is a regression after a certain stage of development has been

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successfully reached (p.231). This coincides with my own experience. On the basis of an entangled relationship with his mother, the schizophrenic child has made tenuous psychological development from which he regresses when faced by difficulties which are too much for him. T h e autistic child appears to be cut off from the mother, and manifests an almost complete arrest of emotional and cognitive development at an early stage. T o use Winnicott's terms, the autistic child is 'unintegrated', whereas the schizophrenic child is 'disintegrated'. Making this distinction between childhood autism and childhood schizophrenia affects our views on early infantile development, and the processes to be inferred there. It also affects our views on the aetiology of autistic illness, and the interpretations that we give in the early stages of the analysis. However, in these early stages, the therapeutic ambience of the analyst's own personality, and the disciplined orderliness of the therapeutic setting are as important as what is said to the child. For example, it is important that the child is not allowed to wander from room to room with the therapist following in his wake, as is the case in some forms of psychotherapy. Those of us who use Melanie Klein's technique of child analysis have come to value highly the procedure she bequeathed to us. Its sensible orderliness with, for example, each child having his own drawer or box of toys seems to be a safe hammock in which child and analyst swing. This containment is important for all children, but particularly so for the unintegrated autistic child. Klein, fifty years ago, was ahead of her time in realizing that not only adults but also children could be psychotic, and in realizing the need for a more precise differential diagnosis, from a psychoanalytic point of view, between the various types of childhood psychosis. She writes:

I think that one of the foremost tasks of analysis is the discovery and cure of psychoses in childhood. T h e theoretical knowledge thus acquired would doubtless be a valuable contribution to our understanding of the structure

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of the psychoses and would also help us to reach a more accurate differential diagnosis between the various diseases. (p.231) Orthodox psychiatric opinion has now accepted that children can be psychotic, but Mrs Klein is still ahead of orthodox opinion today in thinking that some psychotic children can respond to psychoanalytic therapy. This hopeful view has been confirmed by individual child analysts and child psychotherapists. It has obtained indubitable confirmation from workers in the Institute of Childhood Neuropsychiatry of Rome University, who have made a statistical analysis of the results of their psychoanalytic work with thirty-nine psychotic children treated in the Institute's special unit for such children. Their results are striking and rewarding. Later, Klein again anticipates Kanner when she says of Dick's case :

I have reason to think that

... it is not an isolated one, for

recently, I have become acquainted with two analogous cases in children of about Dick's age. One is therefore inclined to conjecture that, if we observed with a more penetrating eye, more cases of this kind would come to our knowledge. (p.231) What a pity Mrs Klein's 'penetrating eye' did not have the opportunity to become focused upon more autistic children. Her theories might have been extended, and certain unfortunate controversies avoided. As it was, she finally interpreted Dick's clinical material in terms of the theories she had formed from her work with other psychopathologies. Mrs Klein states this quite frankly when she says:

I would emphasize the fact that in Dick's case I have modified my usual technique. In general, I do not interpret the material until it has found expression in various representations. I n this case, however, where the capacity to represent it was almost entirely lacking, I found myself

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obliged to make my interpretations on the basis of my general knowledge, the representations in Dick's material being relatively vague. (p .228) Thus her interpretations in the early stages of Dick's analysis would seem to be more applicable to schizophrenic children than to autistic ones. I have analysed ten autistic children, and have supervised several psychoanalytic workers with other such children, as well as observing autistic children for long periods of time, some of these being in their own homes. I have also analysed two schizophrenic children and have supervised other psychoanalytic workers with children of this type. This work has made it very clear to me that, on deep investigation, the psychopathology of an autistic child is very different from that of a schizophrenic one. Thus it has seemed to be important to study childhood autism in its own right, and not to confuse it with childhood schizophrenia, as is often the case. Let me outline what I have found to be some of the essential differences between a young autistic child and a young schizophrenic one. (I use the terms 'confusional' or 'entangled' rather than schizophrenic, since these terms describe the predominating features of their pathology.)

Dr3fferencesbetween young autistic and schizophrenic children The schizophrenic child is in a confused entanglement with his mother. Mahler refers to this as 'pathological symbiosis'. By this means, the child makes some degree of insecure psychological development because, in spite of the interpenetration of mother and child, he has a confused awareness of their bodily separateness from each other. Thus the processes of projective identification as described by Klein are very active and obvious. Such a child is aware of insides and outsides and of objects which, in Klein's terms, he 'phantasies9* are inside *'Phantasy1refers to unconscious processes, 'fantasy' to conscious ones (see Isaacs, 1952).

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the mother's body. He has a capacity for relationships of a bizarre kind. He is 'object-seeking', and has usually developed speech, although this may be slurred and the sentences may be incomplete or have words missed out. Such a child will meeet the eyes of other people, but his own eyes may be blurred and unfocused. T h e autistic child's functioning is very different. His is a sensation-dominated world in which he seeks set~sntiorlsrather than objects as such. He is not responsive to people as people, but mostly in terms of the sensations they engender. His is a primal state of seeking correspondences, in sensation terms, from the outside world which coincide with his inbuilt patterns. If he becomes aware of lack of fit to his inbuilt pattern-seeking propensities, he blocks it out so that he feels continuous with the outside world and not separate from it. He lives in a world of forms and shapes and patterns. If such a child responds to psychological tests at all, it is to those to do with shapes. He seems to be in a state of imitative 'identicality' with the world around him, such as we see in a normal young baby who will put out his tongue in response to his mother doing the same. I n the autistic child, this state has become pathological and he is stuck there. In terms of his imitative fusion with objects in the outside world, he relates to them in terms of the contours of his own bodily parts. Thus, cupboards and chests of drawers are 'equated' (to use Hanna Segal's term) with stomachs; openings in things are equated with mouths. I have much evidence to show that pencil sharpeners are often felt by the child to be equated with his cruel biting mouth. For example, he will put part of a toy into the 'mouth' of a pencil sharpener, whilst at the same time making circular biting movements with his mouth. T h u s when Dick saw some pencil shavings, he said, 'Poor Mrs Klein.' T o him, they were a cut-up Mrs Klein. He was sorry for this 'Mrs Klein' whom he perceived solely in terms of his own activities, and not as a person in her own right. Indeed, he did not see her as a person at all, but as an inanimate thing.

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(Mrs Klein said that he ran around her as if she were a piece of furniture.) As I hope to show later, it is his incapacity to work through such prematurely induced 'sorrow' which has played a major part in his autistic disorder. It seems as if these children have reached the 'depressive position' as described by Klein in a state in which human beings are not clearly differentiated from inanimate objects and are merely experienced in terms of hard and soft sensations. It is difficult for us, as differentiated human beings, to understand such undifferentiated states in which 'me' and 'notme' are scarcely differentiated. Everything is experienced in terms of 'me', 'me' being the flux of bodily sensations which constitute the child's early sense of 'being', even before the 'notme' has been clearly differentiated, although there will be flickering moments of awareness of it. Work with autistic children has convinced me that this primal sense of 'me-ness' has to be well established before longstanding awareness of the 'not-me' can be tolerated. Without it, the necessary selfconfidence is lacking. I n autistic children, this primal sense of 'me-ness' has been disturbed. Thus, beneath their autistic impenetrability they feel exceedingly vulnerable. T o offset this, they feel that they bite off sticking-out bits and pieces. I n the process of analysis, it becomes clear that they have felt that sticking these extra 'titbits' to the surface of their body would protect them and ensure their survival. (Bodily survival is their main preoccupation.) But this feeling that they have bitten off 'titbits' means that, in flickering moments of awareness of separateness, they feel surrounded by cut-up, broken things; the mournful wail of 'broken' often being the autistic child's first word. In Winnicott's terms, in a state which should be one of 'pre-ruth', they have experienced 'ruth'. Biting, which has precociously supplanted sucking, is feared. T h u s they dare not take the breast in the energetic ruthless way of a normal infant, and during weaning the biting of solid food is avoided. Their main emphasis is on surfaces to which they can adhere

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in order to acquire some sense of bodily definition. Such a child lives mostly in a two-dimensional world. If he goes inside a box, or a tunnel, or a cupboard, it is the sensation of being hidden and protected which is significant to him. It is not the going inside. For most of the time, he he has little awareness of the difference between outsides and insides, and also little awareness of time and space. (Some children even try to walk through objects as if they were not there.) Thus, unlike the schizophrenic child, the autistic child has little curiosity about the inside of the mother's body, which Melanie Klein sees as the starting point for all learning. This may be because he has become aware of insides too soon, or because he has never reached this stage. In any case, it is clear from their developmental histories that such children's experience of their mother's body has been very limited. They have sucked very little, and only limply when they did so. Thus they have not learned much and appear mentally defective. k n autistic child avoids meeting the eyes of other people. He does not relate to people in the normal way. They are only significant to him as inanimate objects. If these objects - and people are included in this - seem to become obstreperous (that is, they do not do what the child expects of them) they provoke tantrums of rage and terror. These are dealt with either by ignoring the offending object or by manipulating it to seem part of their auto-sensuous flow. Thus, for most of the time, these children appear 'affectless', as did Mrs Klein's Dick. Apart from these primitive emotions of rage and terror, autistic children do not manifest the emotions associated with sociability such as we see in neurotic children, and even in schizophrenic ones. As treatment proceeds, and they begin to tolerate bodily separateness, the social emotions of love, hatred, envy and jealousy begin to become manifest, but they are not in evidence at the beginning of treatment, when the child is averted from relationships with people. Lacking contact with people as people, such a child has little

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motivation to communicate in the usual way. Language is either absent, sparse or echolalic. All the child's energies are concentrated on engendering a protective covering of 'me' sensations to keep the 'not-me' at bay. The fact that Dick had a few communicative words (for example, he said 'cut' to Mrs Klein) shows that he was not as completely cut off from human contact as many of these children are. Those who care for them feel that they cannot get through to them, and speak of their being in a 'shell'. In treatment, it becomes clear that the child also feels that his body surfaces are hard and shell-like. For example, he often turns his hard back to protect his soft front. It is for this reason that I have termed them 'encapsulated' or 'shell-type' children. However, there is always an opening, however minuscule, through this seemingly impenetrable fasade, and it is this which makes psychoanalytic work possible. For example, such children usually understand something of what is said to them, and they are responsive to the analyst's moods and attitudes, the latter being shown by such things as tones of voice, muscle tensions, body movements and the like. Another feature unique to autistic children is their use of what I have called 'autistic objects'. These will be discussed in Chapter 6. T o the child they are not objects as we see them, but are experienced in terms of the sensations they engender. Since there is no delay in getting the sensations he wants, the child can feel that these objects are part of his body. By means of these sensation objects, he feels completely self-sufficient and without the need for other people. These children will spin or twiddle hard objects, or carry hard objects such as toy cars around in their hand. They cling tenaciously to these objects and will not be parted from them. If they are parted from them, it is as if they have lost a part of their body. Dick was intensely interested in cars and door handles, but he was open to their being used by Mrs Klein as a means of communicating with him. This is not the case when the use of an autistic object has become entrenched, as is the

58 AUTISTIC BARRIERS IN NEUROTIC PATIENTS case with many autistic children. The attempt to use it to get in touch with them is felt by some of these children to be a threat to take away an important part of their body. In autistic children, the manipulation of pathological autistic objects has pre-empted the sucking of normal auto-sensuous ones such as the thumb, the fist, or the fingers. In the undifferentiated state of early infancy, the mother's fingers, the nipple of the breast or the teat of the bottle will also be experienced as auto-sensuous objects. When they first come into treatment, a marked feature of autistic children is that they do not suck their fingers or other objects. This is in marked contrast to the schizophrenic and environmentally deprived young children who usually suck avidly. Instead of sucking, autistic children manipulate hidden parts of their body. These shut out the terror of the unfamiliar 'not-me'. But why does the autistic child have this terror of the 'notme'? It has become clear to me that a crucial factor in the precipitation of the autism was the realization that the nipple of the breast was not part of the mouth, but was separate from it, and could be 'gone'. This had been enraging and terrifying. As I have said, I was first alerted to this by the four-year-old autistic boy whom I have called John (see Chapter 4). I was startled by this boy's revelation to me about 'the black hole with the nasty prick', since it was not part of my Kleinian training. Later, having written a paper about this, I was told by other workers that Winnicott had mentioned this phenomenon in one of his papers, and that Margaret Mahler had just published a paper on this topic. Looking up the references I found that Mahler had written of the autistic child's 'grief and mourning' when he lost what she terms 'the symbiotic love object' (Mahler, 1961, p.332). Winnicott (1958, p.222) had written: 'This loss was experienced as loss of part of his body and not as the loss of the mother and her breast.' Both Winnicott and Mahler saw this as the starting point for childhood autism. Mahler (1961, p.332) writes: 'What we seldom see, and what is rarely described in the literature, is the period of grief and

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mourning which I believe precedes and ushers in the complete psychotic break with reality.' Anyone who sees the mournful eyes of an autistic child will not question that he is griefstricken. I have come to see that a significant factor in the precipitation of psychogenic autism is the fact that the child experienced loss in such an immature state of psychic organization that he had not been able satisfactorily to work over the grief and mourning entailed by the loss. Satisfactory mourning entails giving up the lost object and establishing it as a mental construct. Hanna Segal has shown the importance to symbol formation of dealing with feelings of loss (Segal, 1957). The autistic child has not been able to mourn because the nipple he felt he had lost had scarcely reached the status of an object; it was mostly experienced as a cluster of sensations.

A turning point My experience with John's 'black hole with the nasty prick' marked a turning point, not only for John but also for myself. Finding that other workers had had similar experiences to those I had had with John, I was encouraged to explore outside the boundaries of the theoretical school in which I had been reared. This made me realize that there are states other than those which Mrs Klein explored and described with such courage and penetration. For example, seeing Dick's illness as a schizophrenic one, Mrs Klein placed its fixation point in narcissism. There is much evidence that the roots of psychogenic autism are in the earlier pre-narcissistic condition identified by Freud in the following quotation from his paper on narcissism. The auto-erotic instincts are there from the very first so there must be something added to auto-erotism, a new psychological action, to bring about narcissism. (1914, p.77)

I would modify this statement and suggest that undifferentiated auto-sensuousness is there 'from the very first' and

60 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S that, in normal development, this gradually differentiates into auto-erotism and auto-sadism. It is suggested that in aberrant development, auto-erotism and auto-sadism have developed precociously, which means that erotism and sadism are not directed towards external objects in an appropriate way. This has happened in psychogenic autism which, as was suggested in the previous chapter, is not associated with narcissism, because the autistic child has no sense of being a self. Kohut has cast additional light on this, in that he suggests a further factor which sets in train 'the psychological action to bring about narcissism'. He writes: 'We may thus conclude that the mother's exultant response to the total child (calling him by name as she enjoys his presence and activity) supports, at the appropriate phase, the development of auto-erotism to narcissism' (Kohut, 1971). T h e mothers of psychogenic autistic children almost invariably report that they were depressed around the time of this particular infant's birth, or prior to the autism, if this occurs some time after the birth. For such subdued mothers, the lively, 'exultant response' towards their infant described by Kohut would not be possible. Thus, such infants become trapped in an aberrant auto-erotic and auto-sadistic condition. This has a precocity and artificiality, interlaced with stark terror, which are not part of normal development. Unmanageable erotic excitements and sadistic biting almost obliterate the urge to suck.

Maternal depression as a factor in the development of psychogenic autism In connection with the effect of a mother's depression on a young infant, I was impressed by Brazelton's observation of a normal three-week-old baby when the mother intentionally presented him with what Brazelton describes as a 'still, unresponsive face'. Brazelton records the baby's reactions as follows: he becomes visibly concerned, his movements become jerky, he averts his face, then attempts to draw her into I . . .

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interaction. When repeated attempts fail, he finally withdraws into an attitude of helplessness, face averted, body curled-up and motionless' (Brazelton, 1969, p.137). This description could be that of an autistic child; the 'still, unresponsive face' could be that of a depressed mother who feels herself to be a 'non-person', which is how some of the mothers have described their depression. T h e normal infant soon recovers from such a transitory experience of non-responsiveness in the mother. But for 'stresssusceptible' autistic children, it has been a constantly repeated experience which has had tragic consequences for their ongoing mental and emotional development. I have come to realize that this lack of mental connection with the mother has caused them to overvalue the physical bodily connection to her by means of the nipple of the breast (or the teat of the bottle experienced in terms of inbuilt responses to the breast). For such a baby, the frustration of the inevitable realization that this is not a part of his mouth is a bitter blow from which he does not recover. I agree with Meltzer (1975) and Tischler (1979) in seeing the mother's depression as a factor in the breakdown of normal relations between the mother and her autistic child. I have a great deal of sympathy for these mothers. I n my view, Kanner started a regrettable fashion in seeing them as being 'cold and intellectual'. Ever since he said this, phrases such as 'refrigerator mothers' have been bandied about to describe them. I do not subscribe to this view. Such a mother's depression was not usually a clinical one entailing hospitalization. It was associated with events which are part of the ordinary vicissitudes of life, which impinged upon a sensitive mother at a particularly vulnerable time. For example, the family may have moved house, or the father may have had to be away from home a good deal, or the mother may be living in a foreign country, or it may be a mixed marriage (racially or religiously, or both), or an emotionally important relative may have died, or there may be interfering relatives, or there may be important anniversaries around the time of the child's birth.

62 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S Part of such a mother's difficulty seems to come from feeling unsupported by the father. (This may be a repetition of feelings from her own infancy or childhood.) Thus, she clings to her child as if he is still part of her body. She does this in order to keep going in spite of her depression and lack of confidence. This can happen both when the child is inside her womb and also after he is born. She fears the'black hole'of recognizing his separateness from her. When, for various reasons, the child experiences his separateness from her, she cannot hold him through his states of alarm because they coincide too much with her own. It is not only through states of alarm that he needs her support. Uncontrollable states of pleasurable excitement are threatening also. T h e father of an autistic girl has described how she could not stand states of what he called 'rapture'. However, many relatively normal mothers become depressed as the result of certain disturbing happenings, but their children do not become autistic. I am convinced that there is something in the nature of the child which predisposes him to autism. T h u s it has seemed to me to be more fruitful to investigate the child's contribution to his disorder than to concentrate on that of the mother. We may be able to do something about the child, whereas we cannot change the mother of his infancy. When an autistic child is in analysis, work with the parents would seem to be best directed towards helping the father to support the mother who needs to regain both her own self-confidence and also her love for her nowrecovering child.

Critical factors in the child Recent research work by T o m Bower (1977) and also by Meltzoff and Barton (1979) has thrown light on some of these critical factors. It has indicated that in normal development in relation to certain significant gestalts, the integration of tactile and visual perceptions takes place in the first few days of the infant's life. T h e baby who later becomes autistic seems to be a hypersensitive child, unduly prone to panic reactions. I n these

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children the 'startle response' seems to have become excessively exaggerated. In such children the normal integration of sense modalities seems to have been prevented by uprushes of unmitigated primal panic. The insufficiently buffered shock of bodily separateness from the mother means that the normal integration of touch and sight has been halted, and the child lives in a flat, tactile-dominated world of mere surfaces. Such a child's experiences are superficial and limited, and do not include an interest in insides. In contradistinction to the schizophrenic-type children studied by Mrs Klein, who feel that their insides are full of objects which have dramatic interplay with each other, the autistic child feels empty and objectless. The hard tactile sensations of autistic objects on body surfaces, and the soft touch of autistic shapes, dominate his world. (These are to be discussed in later chapters.) For these children, touch is magical. Only what is tangible seems real to them. The autistic child is trapped in what Spitz has rightly called a 'dead-end street'. But it is a 'dead-end street' with primeval horrors lurking in the shadows.

Primeval terrvrs Whence do these primeval terrors come? Let me make some tentative suggestions about this. Just as in the physical womb of the mother's body the foetus goes through some of the bodily forms of our evolutionary past, so it seems possible that in the post-natal 'womb' of the mother's 'maternal preoccupation' (Winnicott's term) the infant goes through states connected with our evolutionary heritage. Some of these atavistic states seem to be associated with inbuilt fears of animal predators which ensured survival in past ages, but which are now vestigial. In normal development, the infant will be buffered from acute experiences of these atavistic terrors by an ultraresponsive mother who acts as a shock-absorber. A baby who lacks such shock-absorbing primary caregivers is thus exposed to primeval terrors which are not the lot of the normally sheltered infant.

64 AUTISTIC BARRIERS IN NEUROTIC PATIENTS D r John Bowlby (1973) has come upon this fear of predators in children who have suffered traumatic geographical separation from their mothers in their early years. This fear is also in evidence in psychoanalytic work with autistic children who have suffered psychological separation from their mothers in early infancy. Their fear of predators does not always seem to come from an active projection of their own predatory impulses. Rather, these passive children seem to feel at the mercy of terrors of which they are the helpless victims. The foregoing is an imaginative attempt to make sense of some of the savage terrors encountered in psychotherapeutic work with autistic children. In these children, phylogenetic and ontogenetic factors seem to be intertwined. These atavistic terrors have poisoned the child's relationship to his mother. Insightful, professional intervention can draw the fangs of this poison by realizing the part that autistic objects and autistic shapes have played in these children's pathology. These have been reactive protections against the threat to their survival posed by the vestigial terrors to which they have been abnormally exposed, but they have damaged the child's relationship to the mother. This is because the inanimate, tactile, autistic objects and autistic shapes are always available in just the way the child wants them. When their use has become entrenched, the human mother, by contrast, seems very unsatisfactory. Thus, autistic children expect an impossible mechanical 'perfection' from their mother (and their therapist). For example, they expect her to be always with them, always to give them what they want in the exact terms they have wanted it, and to be for them alone. The autistic delights, comforts and seeming invulnerabilities have completely replaced and made impossible the relationship with a real mother who, supported by the father, can give them safeties and satisfactions of more permanent value. Through the infantile transference, informed by insights such as have just been described, the therapist can negotiate the development of a more trusting relationship between autistic children and their parents. As this occurs, the

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parents' desire to respond to their offspring finds an answering echo in the children themselves. The use of autistic shapes and autistic objects, which have been developed to deal with a situation of mental and emotional disconnection from the mother, results in this disconnection becoming intensified. The 'hole' of disconnection becomes a 'black hole' as the child 'negates' the mother because she is not always as available as are his autistic concoctions. Also, his dependency needs are denied and a pathological self-sufficiency results. This is based on fear. Although they do not show it at the beginning of treatment, autistic children are terrified of the 'black hole' or the 'blacked-out' mother. As treatment proceeds, their fears of being 'blacked out' by her are revealed. These are grave misconceptions on the part of such children which, in the early days of psychodynamic investigation, led some workers to think that the mother was 'to blame' for her child's tragic state. This rubbed salt into the wounds caused by the years of unremitting rejection by her child which the mother had experienced. T o say, as Bettelheim does, that these mothers have had 'death wishes' towards their child, before as well as after birth, is both cruel and erroneous. After years of courageous struggling with their own troubles and with their unresponsive child, is it to be wondered at if, as a passing thought, they wish him or her out of the way? But these parents do not get rid of their autistic child. Far from it, they go to many agencies seeking help. In my experience, if they come to a psychotherapist when the autistic child is under seven years of age, and if there are no detectable organic impairments, these insights into autistic objects and.autistic shapes promise to open the closed doors of autism. There are other insights which it is more difficult to make meaningful to the reader. These concern the tactile, sensuous extremes in which such a child lives and moves and has his being. They are difficult for us to understand because these children's predominantly tactile reactions are so different from our own experiences, in which touch and sight are closely

66 AUTISTIC BARRIERS IN NEUROTIC PATIENTS associated, and where mental states are distinguished from tangible 'things'. The shock of unbuffered awareness of bodily separateness from the mother seems to have polarized and fixated the autistic child's sensuous experiences at a tactile level. He lives in a world in which tactile, sensuous opposites such as 'hard' and 'soft', 'light' and 'dark', 'big' and 'little', 'full' and 'empty', 'nice' and 'nasty', and so on, are felt to be in opposition to each other. In the non-cooperative state in which he is immured in which savage rivalry holds sway, he fears that an opposing sensation will totally destroy its opposite: for example, that 'darkness' will extinguish 'light', that 'emptiness' will annihilate 'fullness', that 'bigness' will crush 'smallness', that 'nastiness' will poison 'niceness'. If the 'nasty' sensations cancel the 'nice' ones, he fears that he will be made into a 'nothing' - losing his sense of existence being the autistic child's greatest dread. Such a catastrophe will be fatal. There will be no hope of recovery from it. It is difficult to empathize with these states in which qualities are experienced as fluids and substances. For example, one autistic boy felt that by drawing tall towers he could draw their 'tallness' into himself, and that this 'tallness' would counteract his 'shortness'. Similarly 'shortness' could nullify 'tallness'. In these states, sensuous perceptions seem to have been experienced as tangible 'things' which needed to be controlled and manipulated so that they did not crash into and destroy each other. If he fails in this rigid manipulative control, the child feels that he will cease to exist. It is only as an area of co-operation and reciprocity develops that these opposing states can come into creative conjunction, to transform and modify each other so that other more subtle states are born.

Concluding note Rereading Mrs Klein's pioneering paper has made me realize how much those of us who work with childhood phychosis owe to her far-sightedness (Klein, 1930b). It is primarily due to her example and inspiration that some of us have had the courage to do so.

CHAPTER FOUR

A significant element in the development of psychogenic autism Black was the without eye Black the within tongue. Black too the muscles Striving to pull out into the light Black the nerves, black the brain With its tombed visions Black also the soul, the huge stammer Of the cry that, swelling, could not pronounce its sun. Ted Hughes, 'Two Legends', Crow

T

his chapter, which is a considerably revised version of a paper published in the Journal of Child Psychology and Psychiatry (1966) 7:53-67, concerns a particular type of elemental depression manifested by autistic children. Rank and Putnam (1953) used Edward Bibring's term 'primal depression' (1953) for this type of depression. Winnicott (1958) has called it 'psychotic depression'; Margaret Mahler (1961) has written of such children's 'grief'. My own work has confirmed that this elemental depression has been crucial in the massive arrest of emotional and cognitive development which afflictspsychogenic autistic children. Clinical material will now be presented which illustrates the specific characteristics of such autistic children's grief, and demonstrates why it has been so damaging to their psychic development.

68 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S Clinical material John's parents became worried by his lack of speech and the fact that he seemed different from and slower in mental development than other children of his age. When aged 2 yrs 6 mths, he was seen by a psychiatrist who feared mental defect. However, on being seen again six months later John was found to have made a small, hopeful development in that he now put toy motor cars the right way up. (Previously, he had kept them upside down all the time in order to spin their wheels.) On the basis of this, John was referred for a second opinion to Dr Mildred Creak, at Great Ormond Street Children's Hospital, who had an international reputation as a diagnostician in the field of childhood psychosis. She gave a diagnosis of autism, and then referred John, now aged 3 yrs 7 mths, to me for intensive psychotherapy with the following report: There has been a failure almost from birth to take his milestones in his stride, as if there were a reluctance and drag back at each stage. He now shows so many of the attitudes we associate with autism. His chief interest seems to be to tap different surfaces, orto spin round objects. He is fascinated by mechanical moving parts, and has always been quite clever at learning to move his body. Although he is surefooted he still does not feed himself; not that he cannot - it seems as if he will not. This is what I mean by jibbing at milestones. He shows excessive anxiety at times, with days of screaming, but this aspect is much less evident. He has no useful speech, and only communicates very tentatively by trying to use your hand. Nevertheless, I felt sure he was capable of making a primitive contact at this sort of level, and that therefore there was something on which one could build an attempt at therapy. My deepest anxiety is as to whether the basic determinant of all this may be an inherent degree of mental retardation.

A 'bad family history on the paternal side' was reported. Father's only sister was a hospitalized schizophrenic, and there

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were other eccentric and psychotic relatives. It was also reported that there had been 'tremendous strain' between the child's mother and an aunt who had been mainly responsible for the care of the father during infancy and childhood. John was a first baby. On the physical side pregnancy and birth were normal, but the mother, who came from a remote village in Europe, had been upset by what she felt to be the foreign procedures of an English maternity hospital. She also felt that the nurses prevented her and the baby from getting together in a good feeding relationship. She had a great deal of milk and was very disappointed when breastfeeding could not be established. T h e baby seems to have been a poor sucker and the mother reported that for one week after birth he did not open his eyes. When mother and baby left hospital they went to live with the paternal aunt. Again, the mother felt she was prevented from getting together with her baby, this time by the interference of the aunt. The father was working in another town for the first few months of the baby's life and the mother was insecure and unhappy during this time, but her depression was not such that she had to have treatment. When I saw the parents, they reported that John had had no traumatic experiences such as separations or serious illnesses. He had shown little reaction to the birth of his sister when he was eighteen months old, and had always been a quiet baby. They could give no details about the time at which he first held up his head or sat up, but in the locomotor sphere his development seems to have been quite normal. They began to worry when he failed to learn to talk, and by the strange nature of his play. Bizarre hand movements were reported; he moved his fingers in front of his face in a queer, stiff way. He could not be to put pencil or crayon to paper. Soft fbods would be eaten but he rejected hard lumps. He seemed to confuse his mother's mouth with his own. Bowel and bladder control had not been achieved. I had the impression that the mother had had special difficulty with this aspect of childcare. Remembering her own childhood in which she had exper-

70 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S ienced, on the death of her father, the deprivation of living mostly away from home in an institution, she spoke of her impatience at being a child and her longing to be grown up. The referring psychiatrist gave intermittent but important supportive help to the parents (although, sadly, this was no longer available when the psychiatrist retired). They needed this support, because when the treatment 'holding situation' (Winnicott, 1958) was ruptured on various unfortunate occasions, John had screaming attacks and sleeping difficulties which they found very difficult to bear. The parents were sensitive, intelligent people, and it says much for their concern for John that they maintained support for the treatment during these times and brought him regularly. Without this, the present relatively satisfactory result could not have been achieved.

Course of treatment John was aged 3 yrs 7 mths when he began treatment. At first he came once a week, later three times, and finally five times a week. On his first visit he was expressionless. He went past me as if I did not exist. The one moment when this was not so occurred in the consulting-room when he pulled my hand towards the humming top which I spun for him. At this, he became very flushed, and leaned forward to watch it spin. As he did so, he rotated his penis through his trousers whilst his other hand played around his mouth in circular spinning movements. This suggested to me that he made little differentiation between the movements of the top and those of his own body. He exuded a quality of passionate, sensuous excitement. It convinced me of the importance of maintaining the analytic setting and interpretative procedure if I was to be gradually distinguished from his primitive illusions, and to do my work as a therapist who would help him to come to terms with his sensuous excitements and disillusionments. From now on, I kept to a bare minimum my compliance with the actions he pressed me to do. I made simple interpretations, interspersing them with

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the few words the parents had told me he might understand. These were 'John, Mummy, Daddy, Nina [his sister], pee-pee, baby, potty, spin, spinning'. I repeated the interpretations in several different ways, and occasionally used actions to supplement my meaning - although I kept these to a minimum when I sensed that they were interpreted by him as seductive or threatening approaches. The following are extracts from detailed notes which illustrate John's responses to interpretations. The first reported session is one in which he used his first word with me. It occurred after the Christmas holiday (he had begun treatment in November 1951.) John had no pronouns, so that this, and his limited vocabulary, restricted what could be said in the interpretations, although I had the impression that he understood much more than was implied by the restricted vocabulary he was reported as knowing.

Friday 10 Janua y 1952: Session 9 John now came three times a week. This was his last session of the week. I quote verbatim from my notes: 'As he had done since his second session, he began by playing with the humming top. On the basis of previous material, as well as the manner of his play in this session, I interpreted that he was using his hand to spin the Tustin top so that he could feel that John was Tustin and Tustin was John. Thus he could feel that we were always together.' Immediately following this, he took out the mother doll and handled the bead that joined the handbag to her hand with the same circular movement with which he had handled his penis in the incident with the humming top. After tapping the mother doll he threw her to the ground, saying very plainly 'Gone'. (I interpreted that John was spinning the mummy's bead as if it were his pee-pee to feel he could go right inside the mummy bag, but then he felt it made her into a 'gone' mummy.) He immediately picked up the little girl doll, turned her round and round and ground his teeth loudly. (I interpreted that John was

72 A U T I S T I C BARRIERS I N NEUROTIC P A T I E N T S spinning into the mummy's bag to bite the girl baby, but then he felt he made the girl 'gone' and the mummy 'gone'.) He now took the baby doll and put it in the cot which he turned upside down so that the baby fell out. (I interpreted that he was spinning into the Tustin mummy bag to upset her babies because he wanted to be her only baby.) Following this, he worked the top inside the suitcase provided for his toys, pressing the point into some soft plasticine strips in the bottom of it. Once he touched the baby doll and said 'Baby' or 'Peepee', I could not tell which. (I interpreted that John felt that his spinning made a soft mummy who let him spin inside her to make her babies gone, and this made her into a'gone' mummy.) (During such material, I found my thoughts wandering so that I was in danger of complying with some unspoken request and thus behaving as if I were a part of his body or a toy, instead of a mature, thinking person who was trying to help him to come to terms with his feelings. Other workers have found that this is a not infrequent occurrence with such 'atmospheric' children. Later, I found it helpful to interpret to him that he felt he spun inside my head to make my 'brain children' 'gone', so that he could feel that I was a 'softie' with whom he could have all his own way.) In the above material, we see the beginning of his disillusionment arising from the fact that I can be 'gone', both in the sense of not attending to him, and in the actual bodily sense of being separated from him. This meant that I was not under his control. This was developed further four weeks later, when he spoke two more words. Again it was in the last session of the week.

Fn'day 9 February 1952 :Session 23 Mother and John had rung several times before I could manage to get to the door to open it. As they stood on the step they looked cold and frozen. John had stopped rattling the letterbox; on previous occasions I had had the impression that he felt he controlled me to come to the door by doing this. He mournfully repeated 'Dirty' after

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his mother, as she looked into the orifice of his ear. In the consulting-room he tried to spin the top on the soft carpet. It would not spin. Violently thrusting his hand into mine, he tried to use it as an appendage to his own hand to make it do so. It did not. Spitting with rage and breathing heavily, he threw the offending top to the ceiling. It just missed the electric light. With a crash it fell to the ground and broke into two halves. The inside fell out. Shocked, he went to it and said 'Broken!' and 'Oh dear!' in a grief-stricken way. He spent the rest of the session hopelessly trying to mend it. It seemed that depressing realities were penetrating the autism. There now followed a confused period in the analysis (February - April 1952). During this there was the attempt to make people and things behave in a way,which ran counter to their real nature, as in the incident with the humming top. The toys and myself seemed to be manipulated as if they were his excreta or parts of his own body. During this time he spent most of the sessions lying on the couch playing with his penis, and with his own faeces and occasional bits of plasticine, which hardly seemed to be differentiated from faeces. There was also nose-picking and spitting. This ceased after the three-week Easter holiday in April. This was his second long break in treatment. He now developed an obsessional habit of tapping a button on a cushion and saying 'Daddy!', 'Daddy!' (his father was away from home during this time). This, and the toy he called 'the red daddy bus', played a large part in the analysis during this period. There were tantrums when he realized that they were not part of him and so could go away and leave him. Following this, he would say 'Broken!' 'Gone!' 'Oh dear!' very dolefully (May- June 1952) His first use of the personal pronoun came after he had broken the 'red daddy bus' in such a tantrum. He said, 'I mend it! I mend it!' (Session 118).

Monday 26 November 1952 : Session 130 One day, after changes in the routine of bringing him, he was distressed when

74 AUTISTIC BARRIERS IN NEUROTIC PATIENTS his father, who had now returned home, nearly missed his footing on the front steps as he was waving goodbye to John after leaving him for his session. During this session, John seemed to be trying to maintain that the movements of his body could keep his father alive. (For example, he jumped up and down on the couch, saying 'Daddy mended! Daddy mended!'.) At the end of the session, when he found that his mother, not his father, was waiting for him, he screamed 'Daddy! Daddy gone! Daddy broken!' Following this incident he had a severe nocturnal screaming fit. It was reported to me that in it he had said such things as, 'I don't want it! Fell down! Button broken! Don't let it bite! Don't let it bump!' With hindsight, I realized that these nightmare screams expressed infantile terrors which had been active in relation to the father, the red toy bus, and the button on the cushion, all of which had been felt to be identical with each other. They were not symbols for the father, they were felt to be the father who was undifferentiated from his bodily parts (Hanna Segal(1957) has written of such symbolic equations). But as long as the terrors were scattered in this way, I could not sufficiently understand them to help him to come to terms with them. A session which occurred fifteen months after treatment began will now be reported in detail. In this session terrors which had been adumbrated in previous sessions were brought together, and John was able to use representations by means of words and toys to tell me about them. He could do this because people were now being distinguished as people instead of being used like inanimate objects, such as toy buses, buttons and the like. Thus the autism was much diminished and representational activities were beginning, 25Januavy 1953 : Session 153 (Before giving this session, I should say that in December John had seen a baby feeding at the breast and had shown great interest. I had not used the word 'breast', not knowing whether he knew it. It now came into his material.) He carefully arranged four pencil crayons in the form

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of a cross and said 'Breast!' Touching his own mouth, he'said 'Button in the middle!' (I interpreted baby John's desire to make up a breast for himself out of his own body.) He then put out more pencils in a hasty careless fashion to make a ramshackle extension to the cross. T o this he said, 'Make a bigger breast! Make a bigger breast!' (These children feel called upon to be extra-ordinary, and so they feel they need an extraordinary breast. In the session I interpreted baby John's desire to have a bigger breast than really existed.) He angrily knocked all the pencils so that they spread in a higgledy-piggledy fashion over the table. He said 'Broken breast!' (I interpreted his baby anger that he could not have a breast as big as he wanted.) He said, 'I fix it! I fix it! Hole gone! Button gone! Hole gone! Button gone!' (I interpreted his baby desire to have a breast he could make or break as he pleased.) He again angrily pushed the pencils all over the table and said, 'Broken!' He then opened and shut a wooden box with ear-splitting bangs. (1 interpreted his baby anger that he couldn't have a breast with which he could do as he liked.) He said 'Broken' again and went to the umbrella stand which is in the consulting-room; he put his hand into the glove cavity which is in dark shadow. He shuddered and said, 'No good breast! Button gone!' (I interpreted that he felt that his anger with the breast that would not behave exactly as he wanted it to do made him feel he had a 'no-good breast' with a hole instead of a button.) He went to the case and fetched a piece of dirty grey cardboard and a crocodile. He put them on the chest he had banged. He pointed to the Sellotape round the edge of the cardboard and said 'Icy! Icy!' Then he said, 'No good breast! Button broken!' He slid the crocodile around the cardboard as if it were slithering on ice. His face went cold and pinched. ( I took up his feeling that breaking the breast made an icy no-good breast which was no comfort to him when he was on his own.) Now that the infantile transference was well established and the anxieties were 'contained' in the analysis, his behaviour outside showed great improvement. He was eager to come to

76 AUTISTIC BARRIERS IN NEUROTIC PATIENTS analysis and made good progress in spite of family illness, changes in the routine of bringing him, and family bereavements. He began to admit his dependence and helplessness, and would say of things that were beyond his powers, 'I can't do it! Please help me!' This progress was maintained when his mother and younger sister went abroad and he was left with his father. An unfortunate break now occurred in the 'holding situation' (Winnicott, 1958, p.268). Friday 5 April 1953 :Session 194 I showed him, by means of a diagram, the day he would come back to analysis after the twoweek Easter holiday. Family circumstances made it impossible for his father to bring him back until one week later. In addition, he had been left for one week with the aunt with whom they lived. When he came back I was appalled. He seemed traumatized and frozen. He had a stiff-legged mechanical gait. What speech he had left was stammered. He was indeed in the grip of the 'icy, no-good breast'. This had provided no comfort for 'poor little baby John left all alone on an island', as he put it later. As the bodily tensions relaxed, the night-time screaming fits became such a regular occurrence that the referring psychiatrist prescribed a sleeping draught. During the screaming fits he would hallucinate birds in various parts of the bedroom, and say some of the phrases he had used in his first screaming fit. The birds threatened to peck him and were a great source of terror. However, he gradually began to bring the infantile terrors back into the analysis. He again proceeded with the differentiations he had been making ever since his first word of 'Gone!' He continued to relate to his father in a more real way, and less in terms of a 'thing' like a button that could be broken. He accepted that space and time separated him from me. He put experiences into categories such as 'nice' and 'nasty', and people were classified as 'naughty' or 'sensible' according to whether they did what he wanted them to do. There was the

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beginning of the differentiation between fact and fantasy. He would sometimes say 'It's a story', or 'It's not really true'. He now told me in more detail the illusory terrors that had given rise to the cryptic phrases in the screaming fits. He began to associate the misuse of objects with their being broken. For example, of the humming top he said :'It's broken! Tops don't go on the carpet.' At the end of sessions he sometimes hinted that he felt I left him because he had a part missing, or because he was a 'stinky little goat'. Sometimes he would make as if to break off his 'stinkers' (his word for the hard faeces that hurt his anus), and pretend - a significant development - to drop them down the front of my dress. Sometimes he got rid of his own feelings of silliness by calling his father 'silly' and 'naughty', and to his sister, Nina, as to me, were assigned all the nasty experiences he did not want himself. Thus he demonstrated clearly the fantasy of breaking off unacceptable parts of himself and thrusting them into other people.

Tuesday 28 January 1954 : Session 360 The effect on his psychic development of having his projections contained by understanding was again shown by his use of the pencil crayons which he arranged to make a 'breast'. This was the first time he had done this since the previous occasion eight months earlier, before the unfortunate separation experiences. He pointed to the carefully arranged pencils and said 'Breast!'Then, touching his own mouth, he said, 'Button in the middle!' Then he st009 a pencil in the middle and said 'Rocket!' He called the whole thing a 'firework breast'. This linked with the drawing of a dome-shaped object with brown and red 'stinkers' coming out of it which he afterwards called 'fireworks'. (This had been drawn following a tantrum when I would not let him use my hand as if it were his own.) Holding his mouth as if it hurt, he said, 'Prick in my mouth!' Then, 'Falls down!', 'Button broken!', 'Nasty black hole in my mouth!' Then in an alarmed way, he held his penis and said, 'Pee-pee still there?' as if he

78. A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S thought it was not. (In the session which followed, he said of the broken humming top, 'Broken top! Nasty peoples coming out to blow me up!')

Wednesday 29 January 1954 : Session 361 Material then came about his 'stinkers' burning and piercing the button and making 'a black hole in my mouth'. I asked him about the black hole. He answered simply, 'When naughty things are burned they go black.' Following this he said sadly, 'My nice dreams turn into nasty dreams', and then, brightening up, 'I have my nasty dreams with Tustin.' One day the screaming fits, the cryptic phrases and some of the previous fantasies all came together into one session. Thursday 6 February 1954 : Session 367 H e was in a screaming tantrum when I opened the front door because he had fallen and bumped his head. There was no sign of damage, but he seemed panicistricken as well as enraged. When he stopped crying I took him to the consulting-room. Without taking anything from the case of toys, he went to the table to talk to me. He said, 'Red button gone! It fell with a bump!' H e then indicated both his shoulders with a semi-circular movement and said, 'I've got a good head on my shoulders. Can't fall off. Grows on my shoulders.' He then said, 'It was the naughty pavement, it hit me.' (I said I thought that he was trying to tell me about his fears when he fell down just now.) Touching his own mouth, he said, 'Nina's got a black hole. She had a prick in her mouth. Button broken! Nasty black hole!' (I should have interpreted here that these were his own nasty experiences of which he was ridding himself by attributing them to Nina, but I birked it.) He took the plastic tractor, which was a toy he had attacked remorselessly. He touched the plastic axle, which is not in reality sharp. However, he touched it, gave a huge shudder and said, 'Nasty hard tractor, it pricks.' He spat as though spitting out something that was repugnant. He then screwed himself up

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and screamed loudly. (I reproached myself for not having attempted to put his feelings into words, and so possibly spared him from having to express them in violent action.) In his screaming he pushed away flying beaks. I was afraid that he would fall off his chair, so I took him on my knee and interpreted through the shrieks, The interpretations concerned his feeling that the button was part of his mouth and the destructive feelings he had when he found that this was not so. He then felt he had a 'black hole' and a 'nasty prick' instead of a nice button. He felt he spat the nasty thing into the girl baby whom he felt had taken the button away from him. But then he felt that she tried to spit it back at him and her nasty mouth seemed like flying birds. (We had had material where he had equated the flying birds with mouths.) Without the 'button' he felt that they could hurt him. He was afraid that he might lose his head or his penis, as he felt he had lost his button. For two sessions after this he was afraid of certain objects in the consulting-room: one was the dark glove cavity, another was a penis-like pipe near the ceiling, a third was the 'dirty water bucket'. (This room had no water plumbed in, so there was a jug of water and a bucket for dirty water.) After these sessions the night-time screaming stopped. (It came back after a particularly worrying holiday, and when the question of ending treatment was being discussed.) The hallucinations subsided and did not, so far as I know, trouble him after this:

Closure note Treatment came to an end when John was aged 6 yrs 5 mths. This was earlier and more sudden than I would have liked, but the parents were urging that he finish, particularly as his need for psychotherapy was not now so obvious. He attended a school for normal children. He was making friends, enjoyed school, and was learning avidly. He had a vocabulary beyond that of most children of his age, but this was not surprising since his parents were both intelligent people. He was still a 'finicky' eater. In times of stress he was inclined

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to stammer and to have sleeping difficulties. These remaining symptoms made me want to continue, but since there were signs that he was moving into latency, and since I felt that the parents very much wanted to have John to themselves, I agreed to the cessation of treatment, with the proviso that it might be advisable to seek further help in adolescence. Follow-up It has only been possible to get information about John in a somewhat roundabout way. T h e parents of encapsulated autistic children seem to want to forget the whole experience once it is over. This is in marked contrast to the attitude of parents of symbiotic (entangled) children, who keep contact with the therapist. John's parents did not seek further help. 1 have heard that John attended public day school at the normal age and did well. Later he obtained a good university degree. He has developed into a sensitive young man who is very musical. Discussion child's descriptions John's experience of pi'ef' Such a are probably the closest we can get to crucial, panic-stricken experiences concerned with grief about the loss of a vital object, which John called the 'button'. This was his experience of the nipple of the breast which he had taken for granted, and indeed had not known that it existed, until he discovered that it was not always there. When he became aware that it was not there, overwhelming feelings of disillusionment were aroused, the essence of this grief-provoking situation being partly expressed in his first words of 'Gone!', 'Broken!', 'Oh dear!'. These ejaculations expressed evocations from his infancy, when the loss and seeming destruction of the 'button' had been felt to leave a 'black hole with a nasty prick'. This was John's present day formulation for the previously undifferentiated, unformulated, insufferable experience of sensuous loss which had precipitated the autism. Seeing the baby feeding at the breast had evoked the whole system of illusion which had set

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John's autistic reactions in train. He was now able to get sufficiently in touch with this experience to put me in touch with it also. Being preverbal, it is difficult to discuss in words; evocative rather than theoretical language seems most appropriate to describe it. Recalling the two sessions in which he represented the breast with coloured pencils (Sessions 156 and 360) it will be remembered that the 'no-good breast' with the hole becomes the 'firework breast' with 'stinker' rockets discharged into it by himself. T h e firework, rocket-like discharges had been felt to go into a 'hole' - into a nothingness - instead of being received by a human presence who responded to them in an appropriate way and helped him to manage them. These are very early infantile experiences, in which 'feelings' are experienced in a bodily tactile way as sensations of various kinds. When the 'button' will not stay in John's mouth to be under his control and to be available just whenever, and however, he wants it, he becomes discombobulated. I n panic and rage, the aggravatingly 'naughty' 'button' is felt to be discharged from his body like spit or faeces. It seems to leave a 'hole' in the breast where the 'button' had been. Since his mouth had been undifferentiated from the breast, it leaves a 'hole' in his mouth also. T h e burning sensations of rage make it into a 'black hole'. (As John says, 'When naughty things are burned they turn black.') Putting these preverbal experiences into words distorts their original nature, but both John and I felt that it had to be done, if we were to come to terms with them. 'Acting out' is often the first way in which such primal dramas find expression. But following this way of dramatizing them in psychotherapy, words are necessary if the impulsive discharges are to be contained by thinking about them. As this is done the patient feels that a part of himself, which had previously reacted impulsively in terms of powerful illusions, is being brought within the orbit of thoughtful attention and understanding care. Autistic patients like John have felt assailed by nameless dangers, some of which will be discussed in later chapters. In

82 AUTISTIC BARRIERS IN NEUROTIC PATIENTS order to feel that these dangers were kept at bay, they have needed to feel in control of what happened to them. When they find that they are not in control but, in reality, are weak and helpless, they are devastated. This is well illustrated in Session 367, in which the 'naughty' pavement got out of control and 'hit' John. In this session it was clear that he felt he had lost a part of his body. In his relatively undifferentiated state, he was not sure which part had 'gone'. Was it his head? His penis? Or was it that sensuously exciting 'button'? I had the impression that he experienced his screams as solid, piercing tangible objects; his mouth emitting them as a round black hole. In later sessions, not presented here, he told me that he avoided looking at people's eyes, 'because of the black hole in the middle'. As these agonies and terrors about the 'black hole' were worked over in the analysis, John began to look at people's faces in the way a normal child will do. T h e material presented implies that in the relatively undifferentiated state, phallic and anal sensations were drawn into the primary oral experience, which seemed to affect every orifice of the boy's body. His body, fretted with sore black holes, seemed to face an outside world which was pitted with similar black holes. Empathic identification with John put me in touch with the wordless elemental dramas which had provoked the psychogenic autism. These illusory dramas arose from sensations in his body, the 'button' being the product of these bodily sensations. Let me now discuss this 'button' and the role it played in the development of John's psychogenic autism. The button It is obvious, in terms of John's early sensuous experience, that the 'button' was something more than the actual nipple of the breast or teat of the bottle. Other objects which had similar shapes, or aroused similar sensations, had accreted to it. It was an illusion which could be different things at different times. T h e core of the sensation experience was a

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'teat-tongue' combination. This arose from the lack of clear differentiation of his mouth from the breast. (You will remember that in the referral notes John was reported as confusing his mother's mouth with his own.) Later his penis, his head, his 'stinkers', a toy red bus, a button on a cushion and even his 'Daddy' were all drawn into this 'teat-tongue' combination, probably on the basis of their common sensation of hardness. I t is difficult for us, as differentiated individuals, to get in touch with such undifferentiated modes of operation. In these states objects which, in sensuous terms, have a roughand-ready 'clang' similarity with each other are grouped together and treated as if they were the same. In undifferentiated states, the tendency is to be aware of similarities rather than differences. Thus, objects which, to our more differentiated awareness, seem very unlike are experienced by the relatively undifferentiated child as being the same. T o a young child, a boiling kettle and a steam train may seem to be the same as each other, because the thing that is important to him is the steam. For John, I suspect hardness was what was important to him, because hardness could protect him from the terrible dangers by which he felt threatened. Thus the nipple, his penis, his head, his stinkers, a pipe in the therapy room, a button on a cushion, the toy red bus, and his 'Daddy' all evoked the same reactions. It is not that they are similar and so can be used to represent each other. They are felt to be the same. In John's undifferentiated state the button on the cushion and the toy red bus evoke the same sensations as Daddy does. They did not represent Daddy, they were felt to be Daddy because they evoked the same hard sensuous in~pressionas Daddy did (Session 130), hardness being the trigger sensation. But, so far as John is concerned, these objects had another thing in common as well as hardness - they could all be broken. T h e fact that they were not unbreakable, in spite of being hard, fills John with grief and despair. His desperate efforts to keep himself

84 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S absolutely safe have failed. None of us likes broken things, but to the hypersensitized autistic child a broken thing is not merely a mishap, it is a catastrophe. John's behaviour is not puzzling when we realize that the primary mode of organizing our experience is by means of classification. We sort things in terms of the characteristics they have in common. John's method of classification is strange to us because he sees things as being the same which, to our more differentiated awareness, are very different. For him, objects are sorted in terms of their hardness or softness. Looked at from this point of view, John's behaviour becomes more understandable. In terms of his sensuous reactions, there is logic to his seemingly strange behaviour and puzzling statements. We need to try to think as he does, if we are to begin to understand him. This classifying of objects and experiences in terms of sensuous,!y significant features which they have in common also seems to be responsible for the relatively undifferentiated autistic child's confusion of the configurations of nipple-inmouth, stool-in-bottom and penis-in-vagina. In these children, due to the lack of an adequate capacity for differentiation, as well as to the precocious arousal of auto-erotism, oral, anal and phallic constellations become confused with each other in a polymorphous way. This results in the homosexual tendencies of untreated autistic children. An important part of psychotherapy is the sorting out of such confusions. In. studying autism we find that we are studying the beginnings of perception. The phenomenon of the 'button' seems to arise from inborn nipple-seeking patterns of response which take shape again in treatment. It is obvious that such a nipple-seeking pattern will promote breast - or bottle feeding. Piaget's observations of his own babies complement and confirm inferences derived from psychoanalytic work in respect of this (Piaget, 1954). For example, when Piaget hid a feeding bottle or a toy stork with different parts of the body left showing, he found that it was only when the teat of the bottle or

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the beak of the toy stork were left exposed that the young infant would search for the object; that is, nipple-like objects promoted his response. Clinical work has made me think that such inborn responses are like 'feelers' which reach out into the outside world to mould, and be moulded by, it. In my first book Autism and Childhood Psychosis (1972) 1 suggested the term 'innate forms' to describe them. The 'button' is the result of such an innate form.

Innate fonns These will also be discussed in Chapter 9. They seem to be flexible sensuous moulds into which, at an elemental level of psychic development, experience is cast, and which are modified by the experience so cast. When an innate form seems to coincide with a correspondence in the outside world, the child has the illusion that everything is synonymous and continuous with his own body stuff. In primitive states, patternseeking tendencies are active but, since discrimination is minimal, any one part of the subject's own body, or other people's bodies, or objects in the environment, can seem to be the same. Thus the nipple can be felt to be part of John's body because fingers can be equated with the innate form of nipple; the knob of the humming top could match this form; penis, tongue, 'stinkers', and so on could all be equated with it and with each other. Such unmodified equivalents led to bodily confusions which presaged later mental ones. In this state, live and inanimate objects were treated in almost the same way: for example, the father could be a button on a cushion and the same things could happen to him. In the confused period of the material presented, it seemed that John used parts of his body - and outside objects as if they were parts of body stuff - for the manipulation of what later could become abstracted as mental concepts; much as a child uses fingers or sticks to do arithmetical processes which he later becomes able 'to do in his head'. In these early days, when the fact of his separateness from me was forced upon him, words seemed to be experienced by John

86 AUTISTIC BARRIERS IN NEUROTIC PATIENTS as solid objects. When he was told about the ends of sessions, or breaks in the treatment due to holidays, he winced as if something had been stuck into him. These separations seemed to be experienced quite concretely as broken things which pierced his body. It is difficult to know how to discuss such states, in which the singular feature is that feelings seem to be experienced as physical entities. Absence was 'goneness' 'goneness' was a broken thing - 'a black hole' full of a 'nasty prick'. T h e observer might speak of 'depression', but for John this was a 'black hole'; 'persecution' was a'nasty prick'; 'despair' was felt as taking into his irreparably broken body an object felt to be broken beyond repair. H e did not 'think' about these things; he felt he took them into his body. When the allpowerful, controlling 'button' was gone, uncontrollable dangers rushed in in an uncontrollably painful way. These dangers were experienced as tangible things. Also, the pain of preverbal, preconceptual loss was experienced as bodily rather than mental pain.

The 'black hole' This illusion was the significant element which had set John's autistic reactions in train. This was what was felt to be left when the 'button', and all that it signified, was 'gone'. T h e patient can only tell us about this experience when it is over. When it is happening, he is frozen by it. It was reevoked for John when he saw the baby feeding at the breast. This enabled him to work over his reactions to his breastfeeding experiences. In so doing, he showed me the multiple significances of the 'button'. Absence of the 'button' was not just the absence of 'nice' things which we might intellectually expect it to he, but it was a nasty physical presence - a 'black hole'. When I asked John about this, he said: 'When naughty things are burned they go black.' T h e uncontrollable 'button' was a 'naughty' button which had been burned away and turned black, by the flames of his impulsive rage which he had never been helped to manage appropriately. These children have

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never become toilet-trained in either the psychological or the physiological sense. As well as being associated with feelings that John has not been able to control, the 'button' is also associated with things that will not be controlled by him, and so arouse his uncontrollable rage. It is associated with the top that will not spin, my hand that will not spin it, the 'button' that will not remain part of his body. These children lack sufficient experience of hard 'Daddy' discipline being married to comfortable 'Mummy' softness. They have been left alone to manage their outbursts of temper aroused by frustration. In the outburst in which they unburden themselves, they feel that they explode away a vital bodily part. In their undifferentiated state they are not sure which part it is, or whether it is theirs or another's. Thus as John's fiery rage burned the 'naughty' object that would not do as it was told, he felt that a bodily part was 'blacked out' also. Was it his penis? Was it his head? Was it that sensuous 'titbit', the 'button'? Was it broken off like his 'stinkers'? Was it the hard 'Daddy' bit? In his hypersensitized state, in which everything was exaggerated, the results of his unheld tantrums were experienced as 'catastrophe'. Bion (1962b) has shown that the critical decision for psychic development is whether frustration is avoided, or whether the attempt is made to come to terms with it. Winnicott's transitional area of skills, 'let's pretend' play, humour and aesthetic activities come into being when depression about this catastrophe is experienced, and the attempt is made to control the feelings aroused by frustration. The child learns to sustain tension and to delay action. In the clinical material presented here, we see John's attempts to avoid frustration by explosive projection. On the other hand, his first words of 'Gone!', 'Broken!', 'Oh dear!' show that as soon as he developed even a limited capacity to be in touch with the 'black hole', he began to develop speech (Session 23). Later he was able to re-present his emotional situation (Sessions 153 and 360). Such representation required

88 A U T I S T I C BARRIERS IN N E U R O T I C P A T I E N T S that his impulsivity should be beginning to be held in check, and that he should be beginning to have some capacity to tolerate his separateness. T h e 'black hole' was John's experience .of 'primal' or 'psychotic depression'. As we shall see in Chapter 14, getting in touch with and working over this depression was a crucial situation for the anorexic girl's recovery. Getting in touch with this depression is crucial in the amelioration of autistic states. As one adult patient expressed it, 'You held me firmly so that I did not "break out" and so my "breakdown" became a "breakthrough".' Work with autistic children has brought home to me that such patients need to be held in a firm but understanding 'holding situation' (Winnicott, 1958, p.268).

The 'holding situation' I n earliest infancy, the coincidence of innate forms with matching correspondences in the outside world is the first 'holding situation'. Winnicott expresses this when he says 'The mother places the actual breast just where the infant is ready to create and at the right moment' (Winnicott, 1958, p.238). Bion expresses the same idea when he says 'A preconception mates with a realization' (Bion, 1962b). Mother and baby, teat and tongue, work together to produce the illusion of continuity and to confirm it. T h e 'button' illusion seems to 'button' mother and child together, and also to enable each of them to feel 'all buttoned-up'; falling apart being an existential dread. Both Winnicott (1958, p.238) and Milner (1956, p. 100) have stressed the importance of ample opportunities for such illusion in early infancy, and the dangers of a disastrous impingement of awareness of bodily separateness. But coincidences cannot always be exact, nor can they always be forthcoming, and Bion has increased our understanding of this early situation by delineating the role of the mother as a 'container' for her infant's burning rage, which is experienced as bodily discharge. Lacking an adequate 'conta~ner',the f~erypass~ons of the e nf a ~ ? ~ 9m~ !.c h autlstic chlld have been covered by the ~ c cap

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a child is like a volcano waiting to erupt. When an autistic child starts having tantrums he is beginning to recover. How he is held through these tantrums is important if the recovery is to be sustained. He must never be left alone with them. We must 'talk him through' them. Thus 'held', tantrums can be the beginnings of creative responses. In the North of England, it is common for a mother to describe her child's tantrums by saying, 'He created something terrible!' What a common-sense way to react to tantrums! In early infancy the infant's lack of discrimination, and the mother's adaptation arising from empathic identification with him in the form of 'reverie' (Bion, 1962a, p.309), serve to minimize the explosion-producing gap between primitive illusions and actuality. This empathic reciprocity at first fosters the illusion of bodily continuity, and then gradually acclimatizes the nursing couple to the dimly apprehended fact of separateness. It enables the mother to support her infant through the turbulence arising from awareness of separateness; separateness which seems to be experienced as a break in bodily continuity - as a loss of a part of the body. Changes of state, for example, from 'button-in-mouth' to 'button-gone', inevitably bring tensions, tensions experienced as bodily turgor, to be relieved by bodily discharges. A mother with unbearable, unformulated infantile insecurities, and little support in bearing them, finds it difficult to.take such projections from her infant. I n a way, both mother and child are too alike in their reactions. Such a mother easily succumbs to attacks on her capacity to pay attention to her infant -to hold him in her awareness. Such attacks may come from her own infantile 'privations', or from outside events and people, or from her infant's atmospheric reactions; it is usually a combination of these. They mean that her attention is gone, her mind wanders just as mine tended to do in one of the reported sessions (Session 9). It seems that if a mother, through no fault of her own, is absent-minded, the 'holding' situation' (Winnicott, 1958, p.268) is broken just as

90 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S much as by a traumatic geographical separation between mother and baby. It is feasible that this 'holding situation' is affected by the parents' relationship with each other, in that this will affect the mother's responses to the infant who is the outcome of that relationship. A breakdown in the 'holding situation' means that the naive infant is left to bear intolerable feelings alone. These seem to be discharged into a void to come back at him with renewed force. T h u s stresses and strains accumulate. Continuing to use his own body as if it were another's body, and part of another's body as if it were a lifeless part of his own, means that he remains undifferentiated and cut off from alive human beings who can help him with his troubles. Instead other people are experienced as inanimate things to be manipulated in terms of his needs and caprices. Thus John became more and more enmeshed in the terrors and sufferings associated with the illusion of the 'black hole'. T h e realistic fear of dying pales by comparison with these illusory agonies and terrors. T h e autism had been a reaction to deal with John's explosive feelings in relation to loss of the 'button', for which he felt that no help was forthcoming from the people around him. They seemed to be as frightened of them as he was. But John had cut himself off from such help as was there. In colloquial terms he had 'cut off his nose to spite his face'. This had landed him in serious trouble. As his autism broke down, these impetuous outbursts, experienced as bodily discharges, were released from their autistic wraps. As they were released, other elements in the 'black hole' depressive situation were revealed. These were mourning feelings.

Mourning feelings When I first encountered these feelings, I found it difficult to believe that they could be possible at such a primitive level of psychic development. Finally, however, the evidence was so compelling that I had to face the fact, and help John to face the fact, that he was mourning the loss of the ultraspecial 'button' which could never exist in reality. It was an

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illusion, but an important one. H e felt bereft of a very vital thing. It was like a bereavement. When I was introduced to Margaret Mahler's paper 'On sadness and grief in infancy and childhood: loss and restoration of the symbiotic love object' (1961), I was reassured that I was not reading feelings into the child that were not there. I realized that the 'button' was John's 'symbiotic love object', the loss of which had rendered him numb and dumb. As we worked this over together, we realized that his 'crow-black' sulk about this loss had prevented him from working over the disillusionment that the 'button', conceived in his terms, was not available in the outside world. Another type of baby would have reacted d#erently. As he relinquished his unrealistic hopes of finding the superlatively perfect 'button' in the outside world, it became established as a psychic construct in his mind. This seemed to be the basis for a more trusting relationship with me, based on more realistic expectations. T h e therapeutic 'holding situation' seemed to provide a 'cradle', in which John's baby self could go over early unresolved psychic situations, and modify his unrealistic, perfectionist, exacting demands, both of himself and other people.

Conclusion On superficial observation, organic and psychogenic autistic disorders can look the same. However, on careful investigation, it becomes clear that organic autism arises from gross damage to the brain, whereas in the present state of our knowledge, psychogenic autism seems to arise mainly from damage to the psyche. In my view, psychic damage needs to be investigated as meticulously as the neurophysiologists are investigating brain damage. Global understandings in terms of unresponsive mothers and unresponsive babies just will not do. If we are to be able to help children with the handicap of psychogenic autism, we need to have detailed insight into its nature. In studying this, we find that we are studying the elemental emotions associated with the beginnings of perception, and of

92 A U T I S T I C BARRIERS IN N E U R O T I C P A T I E N T S the ways in which perception can become blocked and distorted. John's revelations give us some insight into this. Later chapters will carry this understanding further. Psychotherap-v with psychogenic autistn An understanding of psychogenic autism is complicated by the fact that in the elemental, relatively undifferentiated state in which psychic damage occurred, such psychic damage is experienced as bodily damage. Since subject and object are scarcely differentiated from each other, the damage seems to happen to both child and object. Both mother and child are felt to lose the vital 'Daddy button' which holds them together. John, a young child suffering from psychogenic autism, showed us the details of this psychic damage. Such a child is in shock. H e feels damaged, weak and helpless. T h e reaction, to counteract this, has been to develop practices which give him the illusion that he is impenetrable, invulnerable and in absolute control. Although they look so passive, such children are little tyrants. In colloquial terms, they are 'too big for their boots'. They need firm but understanding 'containment', mixed with compassion and common sense. They welcome this, for they are as unhappy about their state as are the concerned people around them. From what she told me, I had the impression that John's mother was stunned by the beautiful baby whom she felt she had lost, as part of herself, by giving birth to him. He was not a real live baby to her, but a precious piece of Dresden china. How hurting it would have been to her, and how far from the truth, if she had been told by an 'expert' that she had a 'death wish' towards her child, and that this was the cause of his troubles. Some of the psychodynamicists have made grave mistakes in their approach to autism. This chapter has been an attempt to bring in evidence which corrects some of these mistaken notions. It has also been an attempt to get in touch with the elemental feelings which have provoked the psychogenic autism. In reality, what happened to the children was in the nature of

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a sensuous mishap, but in the hypersensitized, illusiondominated state of early infancy, it had become exaggerated to seem like a catastrophe. But the feelings associated with this illusion had been traumatizing. As one patient said to me, I know it's an illusion, but the terror is real. I have found that this early, seemingly catastrophic damage can be healed by a form of psychotherapy which is realistic about the nature of the disorder being treated. I have also found that insights gathered from such psychotherapy have thrown light on the autistic barriers encountered in certain neurotic patients.

CHAPTER FIVE

Situations which may precipitate psychogenic autism So he took his birth-sneeze in one hand And his death-chill in the other And let the spark scour him to ashes.

Ted Hughes, 'Crow Improvises', Crow

utism is a pseudo-independent state in which the child grimly and stubbornly goes his own eccentric way with no attempt to adjust and adapt to other people's ways. Parents' reports indicate that this is partly because the mother's confidence was being undermined in the baby's early infancy. Thus it had been easy for the child to treat her as a manipulable, lifeless object who was a part of his body. Also, the father's influence, in many cases, was absent or excluded. Now let me instance a few situations which have caused the mothers of the autistic children I have treated to feel underconfident.

A

Undemttning situations for the mothers A large number of the mothers have reported that they were tlepressed before o r attcr the tlmc of the baby's b ~ r t h . 5.ornctrrncs the fathcr had to be away d u r ~ n gthc tlme ot the b ~ r t hand the nlottler had telt unsupported. In other cases there

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were interfering relatives who undermined the mother's confidence. Sometimes the parents had moved house around the time of the baby's birth. In others, the mother was not living in her native country and felt lonely and uncertain. In other cases, mother and father were of different religious persuasions. Some mothers report the death of an earlier baby, or have had a previous miscarriage, the emotional effects of which were still being felt when the later, autistic child was in the womb and was born. Other mothers reported that an emotionally important person had died around the time of the child's birth. In an underconfident and distressed state such a mother is called upon to cope with an infant who, for various reasons, needs especially firm and confident handling. The situations which have just been described are not uncommon, and do not usually lead to autism in the child. For autism to develop, a special concatenation of circumstances has to occur. The primary caregiver's state of mind and that of the rest of the family will affect the developing mind of the baby. A mother who feels lonely and unsupported may be unable to respond adequately to her baby. She will not be able to absorb the inevitable shocks which impinge upon him, such as finding that the nipple is not a part of his mouth; changes from one biological state to another, such as teething; or environmental changes such as removal from one house to another, changes of babysitters, etc. One recovering autistic child spoke of his autism as a 'shock-proof habitat'. This prevented the impingement of shocks and kept him safe, 'safe' being the operative word. Autism is a reaction to promote a feeling of safety when the infant feels that this is not forthcoming from the outside world. As we know, the newly born infant needs extra-special attention. Winnicott (1958) has formulated this in his concept of 'maternal preoccupation'. Bion (1962a) has enshrined it in his notion of maternal 'reverie'. Masud Khan (1964) speaks of the 'protective shield'. This special kind of attention can be affected in various ways. Depression or harassment in the

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mother will affect the fantasies she has about her child both before and after birth. The baby may not seem to measure up to her expectations, or may seem to be the monster or handicapped creature she had feared she would produce, or may be idealized to such an extent that the mother feels that she is inadequate for such a wonderful being. Mothers with recent bereavements may be communing with departed spirits more than with their alive, human baby. This is bewildering to the child, who is called upon to comprehend something which is outside his comprehension. All these are inevitable human reactions on the part of both mother and child. We need to try to understand them rather than make moral judgements. If, in such circumstances, the child has autistic tendencies, the stage is set for mother and child to become cut off from each other. In some cases, something upsetting has also happened to the child which has set autistic reactions in train. Once these have been set going, they are difficult to reverse. Thus, he is a difficult child to rear. Now, having discussed distressing situations for the mother, let me turn to disturbing situations for the child which, when combined with other circumstances, may lead to autism.

Disturbing situations for the child In some cases, autism has arisen after or during a debilitating illness, or surgical intervention in infancy, especially if the limbs have been immobilized (Olin, 1975). But obviously there are many children who have suffered such experiences and who have not become autistic. It is clear that for autistic reactions to become established, a special combination of circumstances has to coincide. Important factors in this are the child's own constitutional tendencies and the emotional climate of the family in which he is reared. Also, it'seems that in situations of biological change the pangs of bodily separateness are likely to be reactivated, and thus may call forth autistic reactions. For example, De Astis and Giannotti (1985) report that they have had several cases

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where autism became manifest at the onset of teething, although they suspect that there had been some fragility in the mother-child relationship before then. An interesting, as yet unpublished detailed observation of an infant by psychologist Shirley Gault (1983) has brought confirmation of the part that the advent of teething can sometimes play in provoking autistic reactions in a somewhat insecure nursing situation. This carefully documented observation shows how a seemingly normal baby met a mother who, due to various external circumstances, gradually became depressed. At weaning, and with the advent of dentition, it seemed as if the child were destined to be autistic. Many specialists were seen, and eventually deafness was diagnosed (wrongly, as it turned out later). This sent the already depressed mother into a downward spiral of increased depression. The baby resorted to inanimate objects, such as; leaves and a piece of muslin cloth, instead of responding to people. However, the encouraging fact about this sequence of observations, which covered the baby's first year of life, is that he was rescued from the downward slide into autism by his own resilience and by the vitality of his father and elder brother. Mother and baby again began to attend to each other, the baby no longer seemed deaf, and all now seems to augur well for the normal development of this baby. It has seemed to me that amongst other precocious developments caused by the trauma of bodily separateness, biting has developed prematurely in the infant who becomes autistic. For a variety of reasons, these children seem to become afraid of their savage biting impulses, and this may, in part, account for their restricted sucking. In a book as yet to be published, Josephine Klein has suggested another possible conjunction of factors which could contribute to the initiation of autism in a child. She suggests that a baby may be born with its sensory apparatus not yet ready for out-of-womb existence but which, over the first few days, or even over weeks and months, gradually matures to a normal

98 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S state. She suggests that by the time this maturation has occurred, the mother's confidence may have become so undermined by her baby's strange unresponsiveness that mother and baby never get together. Other autistic children seem to have suffered disturbances in utem, and so are born prone to be autistic even from birth. Grotstein (1983) has suggested that, as the result of the mother's depression, some of them may have suffered a 'biochemical assault in the amniotic bath'. Rubinfine (1962) has suggested that there could be excessive 'proprioceptive stimulation' in the womb or just after birth. Of course, the mother's fantasies about her unborn child will profoundly affect the developing foetus. The fact that disturbances in utem can lead to autistic-type reactions after birth was brought home to me by a case I supervised recently. This was a little girl who, at three years, was referred for psychotherapy because she had transitory autistic-like episodes in which she went stiff as if with terror, and was impervious to what was going on around her. The significant facts in her early history were that the mother became distressed towards the end of the pregnancy, and that the infant, when near to term, whilst still in the womb, had started to breathe and to defecate, behaviour which denoted foetal distress. Obviously, such a child will be difficult to rear after (s)he is born. A variety of situations can lead to autism. In the past, psychogenic hypotheses have been too simplistic and judgemental. It is clear that several different combinations of factors can result in an autistic picture of varying degrees of intensity. However, in all cases, the autism is an attempt to deal with intense elemental terror. The child freezes like a frightened animal. In every case, the crux of the situation is that mother and child have been prevented from getting together because the mother and child's interest in, and attention to, each other had been disturbed by factors such as have been described. Let me now discuss some of the consequences of this failure of mother and child to meet each other.

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Consequences of the fuilure to meet Several writers have written of the way in which a happy mother and her responsive newborn baby heal each other from the caesura of birth by their sensuous interactions with each other (De Astis and Giannotti, 1980). But for a variety of reasons they may not experience that special psychological ambience, which is probably just as important for the mother as for the baby. If it is lacking it is a tragic situation for both of them; as also for the father, who plays his part in promoting this psychological healing and protection. All the tiny details of family life and infant care generate a healing atmosphere, and lack of it means that the child remains emotionally unattached to his parents. He does not grow emotional roots. Thus he suffers the loneliness of self-incarceration. He is cut off from all those responsive interactions which promote psychic growth. In infancy, the relevant interactions are activities such as sucking, eye-to-eye meetings, playful encounters and caresses. These are the physical bases for that communion between mother and baby which is the first form of communication. Without this the child remains uncouth and unnurtured. His psychic life is curtailed. Lacking adequate memories, he is left in the grip of agonizing terrors about losing his sense of existence - his 'going-on-being', as Winnicott has so aptly called it. Some of these terrors accrete around the basic inbuilt fear of falling. There is the terror of being 'dropped', of 'falling infinitely' (as Winnicott puts it), of 'falling apart', of 'falling to bits', of falling with a damaging bump. There are others such as spilling or dissolving away, or exploding away, or of losing the sense ofphysical continuity with an everlasting entity who is felt to guarantee the infant's existence. These 'nameless dreads', as Bion called them, will be discussed later in the book. For these children, also, the unhealed primary wound of bodily separation from the mother is again laid bare whenever further separation experiences impinge upon them; for example, when they become aware that the nipple of the breast (or

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its substitute) is not a permanent part of their mouth - witness John's experience, cited in chapter 4. In the absence of healing, these traumatic wounds are 'scabbed' over by autistic practices which drive the child further and further away from the healing and humanizing influences of his family and his culture. As David Rosenfeld (1981) has shown, autism 'preserves the traumatic experiences so that they can be dealt with when propitious circumstances arise for doing so, but it does not promote integration. The child is left in a crude, unintegrated state. He does not develop a working simulation of reality which is effective for coping with the exigencies of the outside world in an ongoing way, nor with his own inner states. Let me discuss this further.

The representation of reality As we know, we can never be in touch with ultimate reality. We make a kind of analogue which helps us to function effectively. An important part of cognitive and emotional development is the creation of more and more effective working simulations of reality. In relatively normal development, on the basis of his own constitutional 'blueprint', the child absorbs the constructions of his family and of the culture in which he lives. In the first place, this absorption comes from interactions with the primary caregivers through all the tiny details of infant care. Thus the infant's state of mind, and that of the caregiver, are of paramount importance if progressive and effective working simulations are to develop. Due to a variety of combinations of unfortunate circumstances autistic children have become stuck in crude simulations arising from their inbuilt gestalts and their own bodily processes. Their behaviour becomes automatic and mechanical. I have also come to realize that this can happen in an isolated part of more normal individuals as well. The autistic part in neurotic patients I share Dr Sydney Klein's findings that many neurotic patients

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have an autistic split-off part to their personality. When they get in touch with this, the unhealed psychic wounds of primal separateness are exposed. These have driven them along the road of psychogenic autism, but in a less total way than is the case with the autistic child. Perhaps, even in normal development, such psychic wounds are never totally healed, but throughout life creative interactions promote their healing, to prepare the individual for the ultimate separation of death. Glazing over the wounds with autistic shapes and plugging them with autistic objects prevent this natural healing, because such manipulative activities impede the necessary creative interactions. Neurotic patients with such autistic barriers will be discussed and illustrated in Part Two of this book. In conclusion, let me say a few hopeful words about psychotherapy with psychogenic autistic states. Psychotherapy with psychogenic autism The events and circumstances which have been outlined as contributing to the development of psychogenic autism are only important in so far as they have affected the psychic situation of the patient. They are in the past. We cannot do anything about them. However, we may be able to do something about the patient's psyche. I have come to the conclusion that for the type of autism which has developed to deal with the unhealed psychic wounds of early infancy, psychotherapy is just what is needed. But this must be psychotherapy which is based on a thorough understanding of the nature of psychogenic autism, and its possible origins. In psychotherapy with such autistic states, be they partial or more total, a Pandora's Box opens up before us. If both patient and therapist have the courage to look into its depths, and if they have the resilience and patience to generate the necessary insights, it has been my experience that hope usually emerges from its inner darkness.

CHAPTER SIX

Autistic objects Once upon a time there was a person Almost a person. Somehow he could not quite see Somehow he could not quite hear He could not quite think Somehow his body, for instance, Was intermittent. Ted Hughes, 'A Bedtime Story', Crow

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he chapter that follows is a considerably revised version of a paper which was originally published in the International Review of Psycho-Analysis (1980) 7:27-39. I n working with autistic children I have become aware of their perseverative use of certain objects, peculiar to each individual child, in sensation-dominated ways which impede mental and emotional development. These will be referred to as autistic objects.

Autistic objects Two clinical illustrations will now be given which exemplify the nature of autistic objects: At the beginning of treatment, an autistic ten-year-old boy called David used to bring a dinky car to every session. This car was clasped so tightly in the hollow of his hand that it left a deep impression when he took it out, In working with him it became

AUTISTIC OBJECTS 103 clear that the dinky car was felt to have magical properties to protect him from danger. As such, it was like a talisman or amulet. The difference between David's car and a talisman was that he felt that by pressing it hard into the hollow of his hand it became a hard extra bit to his body. Even if he placed it on the table, the deeply imprinted sensation remained, so that it was as if the car were still a part of his body to keep him safe. Another autistic child called Peter who was six years old at the beginning of treatment used to bring to his sessions a large keyring with over fifty keys on it. It became clear that he felt that this was a hard extra bit of his body. However, during the period when these children felt protected by their autistic objects they were impenetrable to my attempts to help them. Thus it seemed important to understand the nature of these objects and the possible origin of their use.

The nature of autistic objects An outstanding characteristic of autistic objects is that they are not used in terms of the function for which they were intended. Instead they are used in ways which are idiosyncratic to each child. For example, David did not push his dinky car along the table or play with it on the floor as a normal or neurotic child would have done. Peter did not use the keys to open cupboards or doors. He just carried them around. From a realistic point of view they were used in a way which was useless and meaningless; from the child's point of view it became obvious that they were absolutely essential. The hard metal trains and cars which some autistic children take to bed with them to put under their pillows are similarly not used in terms of their intended function as playthings. Nor can it be said that they are used for fantasy purposes. There is a 'let's pretend' quality in fantasy play and a realization of bodily separateness from the object which are lacking in the autistic child's use of his autistic objects. They have a bizarre and ritualistic quality and the child has a rigidly intense preoccupation with them, which is not a feature of fantasy play.

104 AUTISTIC BARRIERS IN NEUROTIC PATIENTS The objects which some autistic children spin obsessively have a similar quality. This brings me to another characteristic feature of autistic objects as used by autistic children. They have no fantasy associated with them. Psychogenic autism is a sensationdominated state, and autistic objects are sensation-dominated objects. As a result of the lack of fantasy, they are used in an extremely canalized and repetitive fashion. They are static and do not have the open-ended qualities which would lead to the development of new networks of association. They are the result of, and result in, repetitive circles of activity which become entrenched. Another typical feature of autistic objects is the seeming 'promiscuity' of their use. The keyring that Peter carried around with him had many keys on it. If one were lost, there was always another to replace it. David did not bring the same dinky car each time. At the beginning of his treatment, it was the hard sensation in the hollow of his hand which was important to him . Many dinky cars could give him the same sensation. Thus it did not matter which one he used. If one dinky car were not to be found, another one would do. Some autistic children have one autistic object which is used for a time in a stereotyped and ritualized way. It is then discarded, to be replaced by another which is used similarly. Thus over a period of time, there may be a succession of objects which have been used in turn, with an intensity which shuts out awareness of anything else. They are used, discarded and replaced by another one. If an autistic object is gone, the child is distressed as if he had lost a part of his body, but the object is soon replaced by another one which is experienced as being the same. However, it is important to realize that the autistic child's inability to tolerate the fact of loss comes from his having experienced excruciating distress about the seeming loss of an instinctually significant part of the nursing mother which had been felt to be part of his body (Winnicott, 1958; Mahler, 1961 ; Tustin, 1972). This loss was experienced as a loss of part of his

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body and not'as the loss of the mother and her breast. It is this situation which has led to the obsessive use of objects which are experienced as if they are bodily parts. The foregoing discussion hints at another characteristic feature of autistic objects. The sensation-dominated state of the autistic child means that such children live in a globally apprehended world. This is very different from ours. We distinguish objects from each other by more than the mere sensation of their shape. We use other clues. Autistic children do not. Their responses are solely on the basis of contour and outline: meaning and function are not taken into account. Thus, at one time, Peter thought that the word 'boiler' was 'boy' with an extra bit to his body. This was not a bit of fun. He was very serious about what, to us, is an amusing misconception. Segal(1957) describes an adult schizophrenic patient who was also operating on this basis of meaningless 'clang' similarities. T o this patient, the piece of furniture called a 'stool' and his faecal 'stool' were equated because the same word was used for both. Another factor which comes into this discussion is that in autistic children the sensory modalities are not always clearly differentiated from each other. Thus, seeing and hearing are often experienced by the child in a tactile way as being touched by the object. Written words which have roughly the same shape are felt to be the same. This applies also to objects, pictures and sounds. This leads to what the observer designates as the concrete nature of the autistic child's experience. As his treatment proceeded David brought evidence of misconceptions which arose from the imprecise, tactile apprehension of the shapes of words. For example, an Aston Martin dinky car was felt to have in it the essence of the.village where he lived which was called Martin. An Austin car was felt to have in it the essence of Tustin. T o those people who have not worked with autistic children this might seem to be an example of rhyming or punning. But these are developed forms of expression when the individual has a sense of his bodily

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separateness from other objects and has a normal perception of them. As he emerged from his autism, David was able to tell me that he had felt that the words 'Tustin' and 'Austin' must be the same because they were the same shape when they 'touched' his ears or eyes. In working with David, it was necessary to help him to realize that bringing the Aston Martin dinky car did not mean that he brought a bit of his village with him: nor did bringing and taking home the Austin car mean that he could carry Tustin around with him. A neurotic child would have used these cars to represent his feelings about his village and about himself. For David they did not represent his feelings. He felt them to be actual bits of Martin and of Tustin. This realization means that in the psychoanalytic situation we deal with such material very differently from the way we would approach it with a neurotic patient. Gradually, as David developed more sense of his bodily separateness from the outside world, it was possible to talk to him about his homesickness for Martin (he was in a small boarding school for autistic children), and his craving to have me always with him (quite literally in his pocket). T o have talked to him about this in the early days would have been meaningless to him because the dinky cars were autistic objects which shut out any sense of missing Martin or myself. An important part of modifying such children's pathological use of their autistic objects seems to be the realization on the part of people caring for the child that these objects are not experienced by him as substitutes for longed-for people. For him, they are that person because they give him the sensations he desires, the sensation of an object being of pre-eminent importance to him. Also, the desired sensation is not localized in any specific part of his body. For example, if the car gave him nice feelings in the hollow of his hand, it was the same as if it were in his mouth. However, even to use the word 'desire' in this context makes the communication inexact. Autistic children cannot become aware of needs, wants or desires because thky have little mental equipment to help them to bear the

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frustration these feelings entail. Instead they use autistic objects. By these they avoid the suspense of waiting. The way in which these children provoke others in their environment to be as concerned as they are to have an autistic object readily available is a striking illustration of their power to keep the autism going and to get others to collude with it. Autistic objects bring almost instant satisfaction, and prevent the delay between anticipation and realization which, so long as the suspense can be tolerated, leads on to such symbolic activities as fantasies, memories and thoughts. Thus the autistic child continues to live in a bodily way, but his mental life is massively restricted. This is why many of these children function as mental defectives when first seen for clinical assessment. This pathological use of autistic objects results in the autistic child's lack of motivation and his lack of basic trust in the 'facilitating environment'. It is only when insightful caring gets through to him that he is able to begin to give them UP. 'Hardness' is a characteristic feature of most autistic objects. This gives the child the feeling that they keep him safe. Autistic chilren, because they lack experience of civilizing relationships with other human beings, feel constantly threatened with being attacked and hurt. They feel that their helpless bodies are a target for savage and brutal attacks. They particularly feel that the projecting parts of their bodies will be bitten off in very barbarous ways. The castration anxiety of neurotic children is mild as compared with the perils that autistic children feel they have to face. The main purpose of autistic objects (that is, objects used as part of the body to give reassuring and diverting sensations) is to shut out menaces which threaten bodily attack and ultimate annihilation. Hardness helps the soft and vulnerable child to feel safe in a world which seems fraught with unspeakable dangers, and about which he feels unutterable terror. These objects help to prevent the realization of bodily separateness, and to promote the delusion that impingements from the outside world are obstructed. One of the ways in

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which they do this is by focusing attention on familiar bodily sensations rather than the strange 'not-me' outside world. But this is the sophisticated view of the observer and, in order to bring clarity to a discussion of undifferentiated states through the differentiated medium of words, it is necessary to distinguish the experience of the observer from the very different experience of the relatively undifferentiated child. For the child, an autistic object is primarily a sensation. But the observer is aware of the object which provokes the sensation. The observer distinguishes differences in objects which all seem to be the same to the child, who only distinguishes them in terms of the sensations they give him as they seem to touch his body. The pseudo-protection of autistic objects (or sensation objects) prevents the child from using and developing more genuine means of protection. In particular, it prevents him from getting in touch with the caring human beings around him who would help to modify his terrors. It keeps him trapped in a bereft state beset with fantastic terrors with no authentic means for these to be alleviated and modified. I have always been puzzled by the fact that some psychogenic psychotic children are reported as having been withdrawn from birth. Whilst writing this paper, it has occurred to me that these children may have chanced upon autistic objects very early in life and have thus been diverted from turning to the suckling mother. A depressed or underconfident mother would not be able to muster sufficient firmness and resilience to attract her infant away from the illusory delights of his sensation objects to the real enjoyments of her breast, which he gradually learns to use as separate from his body. In such a situation the use of autistic objects could become entrenched and pathological.

The on'gzns of pathological autistic objects Our understanding of the origins of autistic objects is helped if we realize that, at first, it is not the milk which is significant to the nursing infant, but the cluster of sensations experienced as

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'mouth-encircled-nipple'. Nature baits the hook, as it were, and ensures that a lifegiving instinctual activity is also pleasurable. But things can go wrong here for many and varied reasons, which can be in different constellations in each nursing couple. The infant is then driven to obtain almost constant tranceinducing ecstasy from his own body to distract his attention from the unutterable pain of the outside world. Clinical work indicates that pathological autistic objects have their origin in hidden auto-sensuous activities which began in infancy. Autistic children often bite their compressed tongue, or the bunched-up pads of their cheeks. Or they wriggle their bottoms to feel the faeces in their anus. All these observations have been culled from the psychoanalytic situation, in which children demonstrate to the therapist what they are doing, or, when they can talk, they will tell her. The children may do other things to which I have not been alerted. As a rule, the caring adults are relatively unaware of these activities because they do not see them. This means that these auto-sensuous activities become more and more deviant and perverse, since outside agencies cannot modify them because they are unobserved. The infants who practise such activities become increasingly odd and eccentric. The autistic objects which such children use later, as if they are part of their bodies, seem to arise from this earlier pathology. This accounts for the idiosyncratic nature of pathological autistic objects. The need to shut out the outside world to the massive degree characteristic of the autistic child arises from a wide variety of situations, all of which seem to occur in infancy. According to my observations, a very common precipitating infantile situation for psychogenic childhood autism is a situation in which a particularly vulnerable child experiences a series of shocks at a time when his neuromental apparatus is not sufficiently developed to stand the strain. These occur in a nurturing situation which, at that particular time, for a variety of reasons, cannot help him to handle it, or cannot handle it for him. A sad situation which often seems to be the starting place for autistic

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withdrawal is a mother and baby who experience bodily separateness from each other as being torn violently apart and wounded (Bick, 1968). Autistic objects seem to plug the gap between the couple so that bodily separateness is not experienced. Unhappily, these delusions prevent a healing, reciprocal relationship between the couple from developing. They have meant that the child had sensation-dominated, inanimate artefacts which blocked his approach to the outside world, instead of human beings who facilitated the gradual development of a differentiated and differentiatingmedium for communication and interpretation.

The deleterious effects of the use of autistic objects Erikson (195 1) is trying to convey the notion of the deleterious effects of deviant auto-sensuousness when he writes that the infant 'will find his thumb and damn the world'. But this notion is not relevant to autistic chidren. In normal development, as Winnicott (1958) has shown, finding the thumb leads to exploration and enjoyment of the world outside the child's own body. Sucking the thumb or the fingers becomes associated with rich fantasies and ideas which enable the child to wait until more appropriate and authentic satisfaction comes. This is not the case with the infant who shows signs of psychogenic autism, in whom sucking has been virtually replaced by the clutching of hard autistic objects. Perpetual recourse to autistic objects means that autistic children have remained in a raw, unnurtured state relatively unmodified by the disciplining and humanizing elements of the nursing situation. They are at the mercy of elemental inbuilt patterns which are stereotyped and unmodified by experience. These are unregulated and have not been coordinated in the normal way. They also seem to be affected by atavistic elements. Such children feel threatened by predatory mouths and creatures. They feel they can be trodden underfoot like insects. They feel they are jostling with other creatures in a desperate effort to survive. It is rivalry 'red in tooth and claw'

AUTISTIC OBJECTS 111 and the hard autistic objects seem to be extensions of nails and teeth. The constant use of autistic objects means that the autistic child has little possibility of learning to tolerate frustration. When frustration impinges, tantrums pound through muscle and vein and cause the child to fear total annihilation. T o counteract this deadly terror he clutches a hard autistic object. This means he never learns to deal with frustration in a considered, thinking way. Such a child has also missed the 'practising' stage of normal infancy which takes place during the mother's absences. For example, when studying the language development of autistic children, Ricks (1975) found that many of them had missed the lalling and babbling stage of normal infancy. My own observations have shown that many of them have missed the normal sucking and mouthing stage when the child creates a working simulation of the breast. This simulation enables him to develop a more skilful and efficient use of the actual breast when it comes. In short, they have missed the early learning experiences associated with play. Such a child expects to do everything at the first attempt without any practice away from the actual situation. When he fails to do this, he desists from effort. This seems to be an important component in the passivity and lack of confidence of autistic children. They have missed the creative work of adjusting illusions, and developing fantasies which Winnicott's (1958) work on the transitional object and transitional phenomena has shown are a bridge to reality. Instead they use pathological autistic objects, which are a barrier to it. They block the apprehension of a reality which can be shared with other human beings in his culture. Nothing can get in but, more important still, nothing can get out. Such objects are the result of primary creativity having gone wrong. Such children's premature and shocking disillusionment means that they have had insufficient opportunities for illusion. Felt needs which are tolerable provoke anticipatory pictures (normal hallucinations) which prepare

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the infant for what is to come. This is the beginning of hope. Instead of creating a valid working simulation of the breast which enables them to use it when it comes, autistic children have developed fake artefacts which replace the breast and for which they do not have to wait. (In neurotic development a rubber 'comforter', if over-used in an obsessive way, long past the time when it is usually given up, can become such a pathological autistic object.) Winnicott writes: 'The mother places the actual briast just where the infant is ready to create, and at the right moment' (Winnicott, 1958). However, as Winnicott well realizes, the 'good-enough mother' inevitably fails in this feat of adaptation to her infant. For the child who is developing normally, these 'failures' on the part of the mother are his opportunity for 'creating' anticipatory pictures and new responses to the mother. As in her absences, so in the times when she does not perfectly understand and meet his needs, he has opportunities for adjusting his anticipatory pictures and adapting to his changing perceptions of her. He learns to wait. H e learns to control his impulsiveness. H e begins to create ideas which are a substitute for the mother, but which do not obliterate his need for her, or inhibit his instinctual responses to her. H e begins to relate and respond to people and situations when they are not actually present. Thus, imagining and thinking develop. T h e frustration of unbearable disappointment means that instead of the creation of healthy illusions and hallucinations which lead on to dreams, fantasies and ideas, the infant begins to manipulate autistic objects in an excessive way. These, being tangible, sensation-dominated and ever-present, keep the child stuck at a primitive level of over-concretized mental functioning. Material objects become unduly important because they stimulate entrancing bodily sensations. Autistic objects develop to deal with unbearable frustration, but they prevent the development of thoughts, memorics and imaginations which, in normal development, in some measure, compensate for the inevitable lack of complete satisfaction w h ~ c hbeing a

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human being entails. Another result is that the children themselves are vulnerable to being manipulated as autistic objects instead of being treated as human beings. The echopraxia of some psychotic children is an extreme example of this. Echolalia is a manipulation of words and sounds as if they are tangible physical objects in order to make them into 'me'. Thus, words can be autistic objects. This echolalic behaviour is often reinforced by the adults around them who, because of the children's non-responsiveness, repeat what they say to the children many times in an effort to attract their attention. This is a good illustration of the effect that such children have on their environment. As Stroh (1974) puts it, 'The parents are forced into walking the child's autistic way.' If, as therapists, we do this and unduly collude with the child's pathological, autistic use of objects, we leave him in the grip of his pathology with no possibility for developing genuine relationships characterized by effort and co-operation. If mother and child become autistic objects for each other, they live in a sensation-dominated cocoon in which they seem to fit each other predictably and perfectly. They become each other's ecstasy. Some autistic children come into treatment with a history of such an idyllic infancy. But the benefits from such an infancy are spurious. A beneficial feature of the bearable lack of fit of the 'good-enough mother' is that it provides a space in which chance happenings can occur. Such chance happenings are agents of transformation and change. The mother and child who become entrancing autistic objects for each other, so that they fit each other perfectly, prevent the possibility of such a space. This means that the child's mental development is massively stunted and goes awry, because agents of change are shut out. In my experience, the father in the family has an important part to play in supporting the nursing couple through the pains and tribulations aroused by the lack of perfect fit with each other, and the realization that they cannot absolutely control each other.

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Such a child never experiences 'missing'. In his concretized mode of experience, absence of a needed person is experienced as a 'hole', which can be filled immediately with an autistic object. He experiences 'emptiness' and 'nothingness', which are different from missing a needed person. T h e persistent repetitiveness of some autistic children in psychotherapy may be the result of our undue collusion with their use of autistic objects. Also, if the analyst is unduly passive and malleable, he can become used as an autistic object. It is progress in the analysis of an autistic child when he begins to miss the analyst. Until this occurs, he has replaced the absent analyst with autistic objects which block any sense of lack and the consequent development of memories which compensate for this lack. Another deleterious effect of the undue use of autistic objects is that in times of extreme crisis hard autistic objects are liable to break under the strain, and to let the child down. This is due to their inflexible, rigid nature, which makes them brittle. It also comes from their being inanimate obects. Alive people can grow and change and be healed. They can recover from states in which they failed the child. Inanimate, inflexible autistic objects can seem to break irreparably. Also, autistic objects are cast in the mould of innate dispositions and in their formation have not been wrought by experience as, for example, the transitional object has been. T h u s they are more liable to snap and break. Such an irreparable breakdown is the source of the autistic child's despair. T h e autistic child (or the autistic child in all of us) is always trying to rubber-stamp the world in terms of rigid systems which seem to be safe. I n doing this, an endless succession of autistic objects is manipulated and these hamper genuine change and growth. Thus it is obvious that the study of autistic objects has implications far beyond the study of the serious mental illnesses of childhood which bring such tragedy to the families in which they occur. They can also bring tragedy to the societies in which we live. However, these wider implications -

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such as the part they play in bigotry and fanaticism - cannot be developed in this chapter, which is concerned with the development of autistic pathology in children.

Therapeutic implications of these understandings Firstly, in the therapeutic situation, this replacement of needed people by autistic objects which help the child to feel impenetrable and safe leads to behaviour on the part of the child which, to the outside observer, appears idiotic, but to the child seems essential. It is only by finding what such behaviour means to the child, and by entering and understanding his world, that we can help him. If we stand outside and merely describe it, we shall try to manoeuvre and manipulate him into our more normal ways of behaving. This will leave untouched and unmodified the rages and panics which give rise to his peculiar state. Also, if we ruthlessly deprive him of his autistic objects we shall expose a hypervulnerable child to unbearable terrors. T o cope with these he may develop an even more entrenched form of autism. Thus, the handling of the transition from the undue use of autistic objects to developing feelings of trust in the alive human beings around him needs consummate tact, patience and skill. It cannot be done in a hasty, mechanical way. We need to wait patiently for the appropriate moments when we can demonstrate to him that human beings, in spite of their unpredictability and mortality, give more long-term and effective support than these objects imbued with excessive auto-sensuousness. Secondly, the foregoing understandings concerning the nature, origins and functions of autistic objects enable us to take a compassionate but unsentimental view of psychogenic childhood autism. Those workers in the psychological and psychiatric field who propose inhumane methods for the treatment of these children may begin to realize that, behind such children's seeming lack of fear, there is a terror so great that it cannot be expressed. This needs to be put into words by the therapist who supports the child in experiencing it. This does

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not mean that unbridled abreaction is the order of the day. On the other hand, those educationists who are unduly permissive in their approach to these children may change some of their attitudes. Both they, and some psychoanalytic therapists, may become more active and rigorous in discouraging and even stopping pathological activities. Some objects may even have to be taken away from the child, so that he can develop more appropriate ways of relieving tension. Or, we may be more strict than we are with neurotic children about whether we allow a child to take toys home with him, or to bring toys from home to the consulting-room. However, any such action on our part needs to be associated with interpretations which show that we understand the meaning of such behaviour to the child. As well as being both more disciplined and disciplining in our technique in the consulting-room, recognition of the impeding efforts of autistic objects will modify the ways in which we couch our interpretations. This should make treatment more effective. As the child begins to feel held in our awareness by our thought, care and concern for him, he begins to hold experiences in his mind as thoughts, memories and imaginations. The undue use of autistic objects begins to wane. As Bion (1962a) has pointed out, the mother mediates sanity to the nursling as well as nourishing milk. By their sensible attention and behaviour, therapists can convey such sanity also. The feeling-tone of the therapeutic setting is of especial importance to autistic children. Thirdly, it has been my experience that an autistic object is often mistaken for Winnicott's transitional object. These understandings concerning the nature of autistic objects should help to prevent this. Confusion between autistic objects and the transitional object leads to mismanagement in both education and psychotherapy, in that the caring person colludes with the use of autistic objects instead of patiently and gently weaning the child from using them so inappropriately, by giving him more authentic means of protection. In terms of Winnicott's (1958) definition of the transitional object as 'the child's first

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not-me possession', it can be said that autistic objects are elemental 'me-possessions'. They are not companionable objects as is the transitional object; their role being that of protection and escape from danger. Also, autistic objects are peculiar to each individual child, transitional objects such as teddy bears and comforting pieces of cloth being objects the like of which many other children use. That is, they have communality in their use (Winnicott, 1958; Gaddini, R., 1978). Fourthly, understanding the nature and function of autistic objects enables us to have a deeper understanding of the ways in which the development of the mental life of autistic children has been impeded. For example, we begin to realize that the autistic child's eccentric and impatient way of relieving himself by the persistent and pathological use of autistic objects has prevented him from learning the appropriate skills and techniques which he can share with other human beings in his culture. Thus, an educational setting in which, as autistic objects are given up, the child can begin to learn from experience and be'helped to make the basic distinctions and integrations which, in normal development, are taken for granted is a valuable adjunct to psychoanalytic therapy. In psychotherapy, we shall be more aware of such children's lack of, or shaky capacity for, symbol formation. Symbol formation is based on the capacity to use substitutes for actual things and situations. It is also based on the capacity to feel separate from the outside world and thus to use abstractions. The use of material objects which are felt to be part of his body and permanently to replace the real thing has prevented the autistic child from doing this. Thus, we shall not read into his behaviour the complicated fantasies and ideas which are encountered in neurotic children, but which are not possible for him. We shall realize that the complicated and esoteric interpretations which are sometimes given to autistic children do not convey to them the meaning they have for us, although they will probably feel 'touched' (quite physically) by our care and

118 AUTISTIC BARRIERS IN NEUROTIC PATIENTS interest. Paradoxically, a more sophisticated understanding will simplify our approach to these children. Fifthly, this understanding of the nature and origin of pathological autistic objects would seem to throw light on the perversions and also on the development of fetishistic objects. There have been attempts to relate Winnicott's concept of the transitional object to the development of fetishism (Greenacre, 1970), but findings from work with autistic children would seem to indicate that fetishistic objects have more in common with autistic objects than with transitional objects. T h e obsessive quality in the use of autistic objects also indicates that they could add to our understanding of the early beginnings of obsessional neurosis.

Conclusion In this chapter, human emotions such as love, hate, aggression, envy and jealousy have not been emphasized as being the main determinants of the child's behaviour. This is not because these feelings are thought to be unimportant, but clinical work with autistic children indicates that distress, panic, rage and predatory rivalry (Gaddini, E., 1969) need to be talked about with the child before interpretations about love, aggression, envy and jealousy will be meaningful to him. There is much evidence that autistic children have experienced an agony, of consciousness in early infancy in which these more sophisticated feelings were experienced precociously and in a compacted way. If we interpret these feelings too soon, before the child has the primal basis to distinguish and bear them, we shall reinforce the precocity which led to the development of an empty fake. Our aim is to help a sincere but tactful child to emerge from the artificial layers of autism with which he has felt protected. T o do this, we have to be in touch with basic elemental depths in ourselves.

CHAPTER SEVEN

Autistic shapes exemplified in childhood psychopathology Shape without form, shade without colour Paralysed force, gesture without motion T.S. Eliot, 'The Hollow Men', Collected Poems

T

his chapter is a revised version of a paper previously published in the International Review of PsychoAnalysis (1984) 11 :280-8. It seeks to study a phenomenon which certain autistic children have called 'shapes'. T h e nature and function of these 'shapes' is investigated, and also the part they play in autistic pathology. Finally, psychoanalytic therapy in which such 'shapes' play a part is described.

'Shapes ' In the days when I was working as a psychoanalytic child therapist with young autistic children, they would tell me, as they began to talk, about their 'shapes'. I knew that shape was important to such children because if they were testable at all (and most of them were not), the psychological tests on which they did best were those to do with the matching of shapes. But

120 AUTISTIC BARRIERS IN NEUROTIC PATIENTS I began to realize that the 'shapes' the autistic children were talking about to me were not those objective geometrical shapes which we all share. They were entirely personal shapes which were idiosyncratic to them, and to them alone. They were not the shapes of any particular object. They were just 'shapes', the circle being an especially comforting one for all of them. I do not know what other forms were covered by what they referred to as 'shapes', but I do know that it was the bodily 'feel' of such 'shapes' which mattered to the child. These 'shapes' brought in the rudiments of the notion of boundaries enclosing a space, although they themselves were not located in external space as are the shared geometrical forms to which we ordinarily give the name 'shapes'. As we shall see later, the feel of an object held loosely in the hand could be a 'shape'. When it was used in this way, the particular features which made it into a specific named object were not differentiated or attended to. It was not the shape of a specific object which existed in actuality; it was just a'shape'. I inferred that it had arisen from inbuilt dispositions in the first place. Later, we shall see that an autistic adolescent girl was concerned to produce a bipartite 'shape' whose two sides were symmetrical, whereas two shapes which exactly matched each other were important to an autistic young man. It is characteristic of autistic children that asymmetry, contraries, differences and lack of fit to shapes are unpleasant and are avoided. With the younger children the 'shapes' of sound, smell, taste and sight seemed to be 'felt' rather than heard, smelled, tasted or seen. Such children's consciousness is very restricted because what they take in is so restricted; 'touch' being an avenue of awareness which, in these younger autistic children, overrides other sense perceptions. Also, conscious and unconscious levels of functioning are scarcely differentiated, although, at times, these children can become agonizingly conscious as the outside world impinges unexpectedly. The children struggled to use words to tell me about these unverbalized experiences.

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It is a struggle for us to understand them. They seem so different from our own more differentiated experiences. However, let me make an attempt to describe their nature still further. T o do this, autistic shapes must first be differentiated from those that can be inferred to be normal ones.

Normal shape-making activities It seems likely that the normal human infant has an inbuilt disposition to form 'shapes'. These primary 'shapes' are likely to be vague formations of sensation. They would tend to offset the randomness of the flux of sensation which constitutes the infant's early sense of being. In the first place, these 'shapes' will occur without the child's intervention. However, the child will soon learn that he can make some 'shapes' recur Gy his own movements. Thus, as well as arising spontaneously, they will become self-induced. These early shapes arise from the 'feel' of soft bodily substances such as faeces, urine, snot, spit, the food in their mouths, and even vomit, some of these being elements for repeated experiences. However, it is the 'shapes' rather than the bodily substances which are important to the child. The bodily substances are merely shape-producers, In normal development, this shape-making propensity will soon become associated with the actual shapes of actual objects. This will result in the formation of percepts and concepts which facilitate a working relationship with objects in the outside world which can be shared with other people. Normal sensation shapes are the basic rudiments for emotional, aesthetic and cognitive functioning. If things go wrong here, then dire trouble is in store. This is what happened with autistic children. Austistic children's 'shapes' In autistic children, the shapemaking propensities have taken an atypical course which seriously hampers ongoing psychological development. Because their 'shapes' are unshared with other people, they become entirely personal and peculiar. They are much more contrived than those of normal children, their use of regurgitation of

122 AUTISTIC BARRIERS IN NEUROTIC PATIENTS food, for example, being similar to that of infants suffering from 'rumination' (Gaddini, R. and E., 1959). Their use of contrivances gives their functioning a stilted, mechanical quality. When they first come into treatment, young autistic children are usually not toilet-trained. At home some of them smear with their faeces, presumably making 'shapes' on their skin. When they become toilet-trained, they manipulate the faeces in their anus to make 'shapes' on the skin surfaces there (outside and inside of the body not being clearly differentiated). This is not to imply that, at this stage, the child does anything as developed as drawing a shape. It is the impression of a shape which these young children obtain on body surfaces. Nor are the skin surfaces differentiated clearly as such, they are merely the medium upon which the impression of 'shapes' arises, some surface media being more sensitive than others. The young autistic children told me that they wriggled or rocked their bodies to make 'shapes' from bodily substances. Spinning and swinging also produced them. The children also bubbled with the spit in their mouth or the snot in their nose. These bubbles were experienced as the 'felt' sensation of a circle, and not as a three-dimensional object located in external space. 1 presume that all the 'shapes' had this two-dimensional quality, although most of them would not have such a precise shape as that of a circle. (In discussing such elemental preimage manifestations which arose in his pyschoanalytic work with the psychosomatic disorders of adult patients, Eugenio Gaddini (1982) makes especial reference to the circle.) ' These autistic 'shapes' were also produced by non-bodily objects and processes experienced as if they were bodily ones. The 'felt' shapes produced on the child's bodily surfaces by these non-bodily objects and processes did 'not lead to their being shared with other people, as is the case with more normal children. The objects and processes were at the service of the autistic child's entirely personal idiosyncratic purposes. Like the bodily substances they were merely shape-producing

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agents. They scarcely existed in their own right for the child. Some young autistic children are so unaware of the actual existence of objects that they try to walk through them as if they did not exist. I n the same way, they listen to other people's voices, not as a communication but as a self-envelopment by lulling shapes. Thus they are often thought to be deaf before it is recognized that they are autistic. The children are capable of forming elementary percepts and concepts from their shapemaking propensities, but these are idiosyncratic to them, and they are not very interested in them; they are so captivated by 'shapes'. The non-bodily equivalents to bodily substances are such things as mud, sand, plasticine, clay, water, paint, and so on. As we shall see later, toys can also be used in this way. Also, we shall meet a thirteen-year-old girl who used arithmetical notation, and an eighteen-year-old young man who used the letters of the alphabet as equivalents to bodily processes. The necessary quality of these equivalents is that they lend themselves to being manipulated as 'shapes'. These 'shapes' are not the differentiated shapes of actual objects as we see and 'feel' them. Nor were the arithmetical and alphabetical processes used as we would use them. They were used as contrivances to produce the 'shapes' that the child wanted. Autistic children are 'stuck' in this peculiar mode of functioning. Very little ongoing psychological activity takes place. There was another important way in which the autistic child's 'shapes' were different from those of more normal children. They were repetitive and unchanging. Metaphorically speaking, they went round and round in an unbroken sequence. Unexpected, spontaneous 'shapes' which popped up out of the child's control were upsetting. They struggled laboriously to shut out the unexpected 'shapes' by trying to make the known and familiar ones recur again and again. They felt that things must not get out of their control. T o the child, bodily movements were felt to be all-powerful to produce known and familiar 'shapes'. These 'shapes' were also felt to be

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all-powerful in that they could make the child feel soothed and comforted or, if they got out of control -for example, a loud and unexpected noise hitting his ears - they could upset him. 'Shapes' had powerful effects upon his moods. He tyrannized over them and they tyrannized over him. He was enthralled by them. The child felt that the existence of the magical 'shapes' depended upon his activities, and that he depended upon their magical presence to give him a sense of 'being'. Just as the philosopher Bishop Berkeley felt that his'looking' created the world, so autistic children feel that their 'shapes' are all-powerful to create it. With the younger autistic children, these were primarily 'felt' shapes; with the older children sight became important also. Of course, we all create our world in that, in terms of our modes of perception, we construct a working simulation which helps us to function in what we quaintly call 'the real world'. We all share the experience of the Scandinavian god Odin who, at the beginning of time, before he could create the World, leaned over a bottomless chasm until the swirling mists below formed themselves into shapes. 'Shapes' are the primary means by which we create both our inner and our outer worlds. The trouble with autistic children is that their 'creation' is unduly 'quirky'. They have used the shape-making propensities of the human mind in their own, idiosyncratic way. The evolution of their construction has not been modified by co-operative interplay with other people. It is also unduly suffused with crude auto-sensuousness. This makes the children pick up the wrong cues for ongoing psychological development. They becoae trapped in a vicious circle from which they cannot escape. Only what they can easily manipulate seems real. 'Shapes' are easier to manipulate than actual objects used as actual objects, thus 'shapes' seem more real. This means that the activities of autistic children are mostly asymbolic. They do not play, dream, fantasize or imagine to any appreciable extent. It is progress when, in treatment, such a child has visual hallucinations. (The 'shapes' may be a kind of

125 tactile hallucination.) They do not suck their fingers or their thumbs. Nor does genital masturbation appear. It is progress when they do these things. It is great progress when they begin to play. Through lack of contact with other people's 'shapes', which could change and transform their 'shapes' into common coin, they are cut off from the enriching psychological possibilities of everyday life with ordinary people. Their thinking, if it can be called such, is restricted and meagre. Imagination is completely lacking. Speech is either absent or cripped by echolalia. Their emotional life is similarly muted, except on the rare occasions when it bursts forth in an explosive way which is terrifying to the child. In Greek mythology Morpheus, the son of the god of sleep, could change his shape at will. From this we get the term 'morphology'. Winnicott has suggested the term 'psychomorphology' for the study of psychological forms and shapes. This chapter concerns an aspect of psychomorphology which is concerned with non-objective shapes. We live in a world dominated by words and by the shapes of actual objects. In studying autistic children we have to try to enter a wordless world dominated by self-induced, amorphous, unclassified, concocted 'shapes'. Writing this chapter has brought home to me how difficult it is to cross the threshold into this world. The reader may be finding it as difficult as I did. T o help you to understand it, try a little experiment. Forget your chair. Instead, feel your seat pressing against the seat of the chair. It will make a 'shape'. If you wriggle, the shape will change. Those 'shapes' will be entirely personal to you. T h e autistic child's attention becomes so focused upon these entirely personal 'shapes' that the chair, as such, is not important to him, although he may be vaguely aware of its existence and may even know its name. Perhaps this has made it a little clearer. It may become clearer still when these 'shapes' are seen in action in actual children. CHILDHOOD PSYCHOPATHOLOGY

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Autistic 'shapes' in action T h e stereotypes which are so characteristic of autistic children are an exhibition of the child's shape-producing activities. Mrs Shirley Hoxter described a moving example of such a stereotype when she wrote as follows: On my way to the clinic, I drive past a couple who are slowly making their way along the pavement - apparently a father taking his twelve-year-old(?) daughter to school(?). Every now and again the girl stops, obviously immovable, she holds u p her hand, twists it and twiddles her fingers, gazing at it in entranced joy. Nothing else in the world exists and certainly there are not joys like this to be found elsewhere. Her father stands by, patiently waiting for long minutes like someone resigned to chronic, repeating spasms of pain. T h e eternity of suspended time is over. They proceed on their way for a few yards and then it is repeated. (personal communication) As I read this account, I feel full of sadness that the girl could not turn to her caring father for comfort and reassurance from her terrors, instead of resorting to her concocted, self-induced 'shapes'. But at twelve years of age this is likely to have become an established way of life. It would be very difficult to help her to change it. However, it has been my experience that it is possible to bring about changes if autistic children come into psychotherapy at under seven years of age or thereabouts. If such psychotherapy is to be tactful and sensitive, we need to understand some of the functions that 'shapes' have for the chidren. However, before discussing them, autistic 'shapes' need to be differentiated from autistic 'objects'. This latter phenomenon was described in a paper published in my book Autistic States in Children (1981). Such 'objects' had been hinted at in my earlier book Autism and Childhood Psychosis (1972). I understand them better now. As one lives with such elemental phenomena they become better understood and their

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critical importance to psychotherapy with autistic children becomes realized. (I now prefer to call them 'auto-sensuous objects', particularly in their normal manifestations; 'autistic' can then be restricted to pathological ones.)

Autistic 'objects' Autistic 'objects' also arise from self-induced bodily sensations. Like autistic 'shapes' they arise from autosensuous activities. Their difference from 'shapes' is that they are stimulated by hard bodily substances such as hard faeces, hard snot, hard muscles, and hard bunched-up tongue or the insides of the cheek. They are experienced as clusters of hard sensations. In these instances the child's body is tight and taut. Later, hard objects such as toy cars, toy trains, keys, etc., are used as if they are part of the body to give the child the same sensations as those aroused by the hard bodily substances. The actual, detailed features of the objects are not attended to other than those that the child wants. These are the 'feel' of their surfaces and outlines. Autistic 'objects' are different from the soft, amorphous 'shapes' in that, as well as being hard, their outlines are rigid and static. They do not change as those of the malleable, fluid 'shapes' can do. Both Bick (1968) and Meltzer et a/.(1975) have described the way in which unintegrated children feel that their skin surfaces 'adhere' to other surfaces in order to offset their terror of falling apart or spilling away. Autistic 'objects' meet this need. The autistic child presses a skin surface against the hard surface of an object, for example, a small car held tightly in the palm of his hand. The hard, well-defined cluster of sensations caused by this gives him a sense of bodily definition as well as making him feel secure and safe. Since the child's body becomes equated with the hard objects to which they adhere, 'adhesive equation' would seem to be a more appropriate description of them than the term 'adhesive identification' as suggested by Bick (unpublished paper). Bick was obviously dissatisfied with this term since in private communications she changed it to 'adhesive identity'. Based on Eugenio Gaddini's

128 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S useful clarifications (1969), 'imitative fusion' would seem to be another possible description. It is important to realize that, since the child's body seems fused with 'autistic objects', these have scarcely reached the status of an 'object' in the usual sense of that term. The child's attention becomes so riveted upon these hard, object-like clusters of sensations that they prevent the normal use of actual objects, distinguished as actual objects which are separate from the body. They also prevent the development of relationships with people, who - by contrast with autistic 'objects', which are always available - seem unreliable. 'Autistic objects' need to be differentiated from Winnicott's 'transitional object' which, having reached the status of an object, and being a combination of 'me' and 'not-me', can facilitate ongoing psychological development. Let me now return to the discussion of autistic 'shapes' and try to elucidate their function for the child.

The function of autistic shapes As well as distracting the child's attention away from the 'not-me' outside world, the perseverative recurrence of self-induced, familiar 'shapes' is important in calming autistic children after an explosion of tantrum or ecstasy. These extreme states are terrifying to such children. They feel that they will be blown apart and spill away. The hardness and definition of autistic objects helps the child to feel safe and secure - they feel 'all buttoned-up'. The amorphous softness of auto-sensuous shapes is soothing and comforting. They are like a self-induced warm bath which is always on tap. The 'shapes' induced by bedwetting are an example of this function. Mr Park, the father of an autistic adolescent girl, Elly, has written an interesting paper in which he describes the obsessional 'shapes' Elly used to calm herself down after such explosions (Park and Youderian, 1974). He calls them 'ordering principles'. Twelve-year-old Elly's shape-producing equivalents of bodily substances were numbers. For Elly some

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numbers produced 'nice' sensations and others produced 'nasty' ones. Some numbers aroused such 'rapture' (as the father terms it), that they were unutterable; Elly could only write them. The moon was number 7 for Elly. The father describes her unutterable rapture about the full moon. 'On the nights following a full moon, it rises outside Elly's window and stays for several hours partly visible behind a large tree . she will not say its name but will refer to "something behind the tree". . . if the moon is obscured, Elly lies in bed and cries her tearless autistic cry' (p.316). As well as the moon's being number 7, so were the sun and a cloudless sky. Seven was a rapturous number. Elly had a system of doors based on numbers with which she dealt with her states of rapture. Here is her drawing of that system :

..

The sun with many rays and no clouds obscuring it represented Elly's greatest joy. For this, she had to have four doors to cope with her ecstasies about it. A sun with fewer rays and one cloud

130 AUTISTIC BARRIERS IN NEUROTIC PATIENTS needed three doors. A sun with even fewer rays and three clouds needed one door, whereas the sun with scanty rays and four clouds obscuring it needed '0'doors (p.3 16). In this we see the number basis of Elly's world. Just as a younger child would have used the 'shapes' arising from his bodily substances to create his world, so Elly used the 'shapes' arising from numbers. This meant that she expected arithmetical precision both from herself and from other people. Enraged frustration resulted when her calculations were disappointed. Mr Park gave an example of this. It occurred when a guest took the first helping from a salad which Elly had made, and from which she had arranged in her mind that she would be the first to take a helping. Another person's unexpected action disturbed her world. T o calm herself down after the tantrum which this provoked, she embarked on a skilful manipulation of multiplication and division sums with large numbers, to which she knew all the answers beforehand. From these manipulations she got 'shapes', in this case the answers to her sums, which were known and familiar. These numbers were completely at her service and under her control. She manipulated them so that she got 13691369 as the answer to her sums. For Elly, the symmetrical 'shape' of such a number was always comforting. The two sides were the same; they matched each other. This desire for matching 'shapes' and fear of lack of fit for 'shape' was illustrated by an autistic eighteen-year-old whom I will call Tony. As with Elly , Tony's autistic condition had been ameliorated by a caring family. After being sheltered by this family and by a Rudolf Steiner school, Tony expressed the wish to go to the local college of further education, which he did at seventeen years of age. This was too stressful for him. He had a breakdown in which he deplored his loneliness. T o solace this, and to calm himself down after the upsetting experience of the college, he resorted to what he called his 'play'. This concerned 'shapes'. The caring parents could only sit on the

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sidelines. They were completely cut off from him. The headmaster of the college suggested to them that it might be helpful to Tony if he made a tape recording of his'play'. He was very willing to do this and the parents have allowed me to make a copy of this tape recording. The essence of what Tony said was that the right people had to be 'matched' with the right house. The letters of the alphabet were used as the basis on which this 'matching' took place. For eighteen-year-old Tony, the letters of the alphabet were equivalent to the malleable bodily substances of the younger child, from which comforting 'shapes' would be manufactured. The alphabetical system from which Tony's 'shapes' were made is as follows. If people had certain letters in their name, for example d,o,m, then they would match with a house which had a name that contained those letters. This idea was repeated over and over again throughout the 'play'. Thus, Tony reinstated his comfortable and reassuring view of the world by enveloping himself in repeated familiar shapes which matched each other. (I should say here that neither Tony nor Elly had had psychotherapy, so their material was quite unaffected by psychoanalytic ideas and by my views on 'shapes'.) These children are powerful enough to impose their private pattern of concocted 'shapes' upon the public shapes of the outside world, and to get people to collude with these. They want to keep everything on a dead level of sameness. Extreme states of ecstasy or tantrum threaten to send them 'mad' with excitement. In popular parlance, which is very revealing, they threaten to send them 'off their rocker'. Both Elly and Tony illustrated their frantic attempts to get back on to their 'rocker'. Mr Park describes how Elly would sit in her little rocking chair, listening to hard rock music. When it threatened to become too much for her - that is, when it threatened to send her 'off her rocker' - she would cover her ears to shut it out. Perseverative, solitary rocking is very characteristic of these children. It is their self-made brand of tranquillizer. The self-induced autistic

132 A U T I S T I C BARRIERS IN N E U R O T I C P A T I E N T S objects and autistic shapes stimulated by this rocking are not so much an attempt to express feelings as an attempt to clamp down on them and to banish them. Of course we all do this to some extent, but in autistic children it is a perpetually dominant state. Thus, their inner and outer worlds do not grow and change as do those of more normal individuals. They are not sufficiently modified by interactions with the actual characteristics of actual objects and with those of other people. Their simulation remains a freakish construction which does not help them to relate effectively to the actualities of the outside world nor of themselves. Thus, the 'not-me' becomes increasingly strange and frightening to them. Autistic objects and autistic shapes divert their attention away from this strange, frightening 'not-me'. The more their attention becomes focused upon these autistic procedures, the more remote and strange the everyday world of ordinary people becomes. Thus, the effect of these practices is that of alienation. In studying autistic shapes and autistic objects we are studying the anatomy of madness. An important part of psychotherapy with these children is to lead them away from their idiosyncratic autistic world into the shared world of sanity and common sense, whilst at the same time preserving their originality and individuality. T o do this tactfully and skilfully we need to understand the nature and function of their diversionary distractions. For this we need to have some understanding of why they may have resorted to them. After many years of work with autistic children, I have come to think that psychogenic autism is the result of an interaction between a temporary state of depression or underconfidence in the mother during the child's early infancy, and the particular nature of the child (for an insightful understanding of the mothers of these children, see Tischler, 1979.) Also, the father, in my experience, has played a negative part in that he is either absent, or too malleable for this powerful child. Although as infants these children were physically well-cared-for, the psychological ambience surrounding them was not adequate for

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their needs. Ordinarily, the mother, in co-operative interaction with the father, provides the child with a means of interpreting and managing the world of sensations and emotions. Lacking this, the autistic child has invented his own naive scheme concocted from repetitive self-induced shapes. Excessive autoerotism stimulated by certain material objects has attempted to compensate for their psychological lacks. Thus, 'me'-centred manipulations and auto-sensuality have remained unduly important. By nature, autistic children react to difficulties by retracting their psychological feelers. They opt out. This lack of empathy affects their capacity to relate to other people (Hobson, 1986). Also, work in the Institute of Childhood Neuropsychiatry of Rome University suggests that some of these children may have minor brain irritations and hormonal imbalances (De Astis and Giannotti, personal communication, 1983). All this makes them tricky infants to rear, even when a mother is functioning normally. It has seemed to me that what began as their particular .reaction to the mother's underconfidence and inattention becomes hardened over the years into terror-stricken strategies. Almost the whole of their attention becomes focused upon rigid contrivances, and thus they seem to be inaccessible to human care. Without decisive therapeutic intervention, they continue on the treadmill of their repetitive, all-powerful 'shapes' which are facile rather than facilitating. Let us now consider the type of psychoanalytic therapy which can modify the child's recourse to such restrictive practices.

Psychoanalytic psychotherapy Such psychotherapy gives the autistic child the chance to meet some of the inevitable facts and frustrations of life, but in a protected and caring setting. Frustration is inevitable because no psychotherapist, however good, can understand him all the time. The interpretations are not always accurate, nor do they always meet his needs. Sometimes they are not even un-

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derstandable by the child! Nor are the shapes which occur as precise as these exacting chidren demand. There are inevitably holidays, and days when the therapist is not working as well as usual. From this point of view alone, psychotherapy is a very salutary experience for these children, for they meet these facts in a situation in which the therapist's only work is to listen to them and imaginatively to try to understand their difficulties whilst strengthening them to meet them. But understanding does not mean sentimental collusion with their pathology. Such children are pied pipers who have led their 'shapes', and will lead us if we are not careful, away from the concourse of human beings into the darkness of the autistic mountain. We must not 'walk the child's autistic way', as the late George Stroh expressed it (1974). However, 'calling their bluff' without a therapeutic ambience to relieve and contain the murderous rage provoked by this is unnecessarily assaulting, and is likely to result in further autistic manoeuvres. If we are to help these children to change, we need to have therapeutic insight into the use their autistic behaviour has for them. We do not strip them of their means of comfort and protection without providing something better. Autistic objects and autistic shapes are not merely psychological curiosities. They are barriers to more normal functioning. Insights into these phenomena promise to be the keys by which we can tactfully enter the world of the autistic child to enable changes to take place there. These changes result in the child's becoming interested in using the percepts and concepts which he can share with other people. These process incoming information and facilitate co-operation with other human beings and with the object world. Some workers have become pessimistic about the possibility of basically reorienting an autistic child. They think that the only changes that can take place are the development of ever-widening circles of more and more complex autistic functioning, and that their autistic pivot will remain unchanged. In my experience, these insights into autistic objects and autistic shapes promise to

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provide a means whereby the child's autistic approach to life can be radically changed. The precise details of how this occurs in psychoanalytic therapy are still somewhat mysterious, but that it does occur, particularly with younger chidren, is borne out by my own experience. (Some older children have been habilitated.) However, if it is not to be damagingly intrusive, such a transforming entry into their world has to be insightfully tactful. At these levels we are working with psychosomatic and neuromental elements. The therapist has to use those human resources which are suitable for these levels of functioning - the human being's capacity for empathy with another person's states is the psychotherapist's most valuable asset when working with such children. Psychotherapy is an art as well as a science. As in all detective work, progress in understanding comes from empathic identification with the person being studied, by imaginative reconstruction of his situation, by informed and inspired guesses, as well as by careful following of the clues. If we are listening to them, the children will often put us right if we are wrong. When children introduce us to their 'shapes' it is a sign of developing trust. It is important not to abuse this privileged entry into their world. We need to be careful not to use our knowledge to impose a conformity on these children by flattening out those private personal shapes which will become part of their originality and individuality. These children are often poetic, artistic and musical. We do not want them to lose these gifts. And, after all, a little eccentricity is refreshing! Good psychotherapy is a kind of sanctuary in which private 'shapes' can be safely shared with someone who respects and reveres them. In Bion's (1962a) terms, they are held in a caring person's 'reveries'. Let me now summarize a psychotherapy session with an eight-year-old boy, whom I will call Peter, talking about his 'shapes'. For those who are interested, this session is given in full in my book Autistic States in Children. This session was a

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turning point for Peter, who made a definite move out of his autistic way of functioning to becoming more accessible and cooperative. The week before this session occurred Peter had asked his mother what 'autistic' meant. I do not know what she told him, but she ended by saying that Mrs Tustin was helping him with this. This information seemed to be operating in the session. Also, at the end of the session his mother told me that Peter had been very constipated. As you will see, this seems to be operating in the session also. His revelations about 'shapes' had been heralded in the last session of the previous week when he told me that he made shapes on his skin by tickling it, and also by making bubbles with his spit. Up to the time of the session reported here, he had never done anything approaching what could b; called play. At the beginning of the session which is being reported, he went to the drawer which contained his toys, so I was both surprised and pleased. He was now talking, though somewhat laconically, so when he took out the toy giraffe and started to tie a long piece of string which went around the giraffe's body, I asked him if he was thinking about the giraffe which had fallen down. The news bulletins on the radio had been full of a giraffe in a zoo which had fallen down; ropes had been used to help it to stand up because if it did not stand up it would die. It seemed as if the whole of Britain was in suspense as to whether the giraffe would be hauled to its feet so that it could live. It was clear that Peter was very worried about this giraffe and, indeed, identified with it. I talked to Peter about his feeling that he had 'collapsed', 'flop' or 'collapse' being the child's way of experiencing the psychotic depression which is at the centre of autism. Peter said the giraffe had to be 'raised up', so I talked with him about his wish to grow up properly and not to be 'flopped'. After he had hauled up the giraffe on the string from the bottom drawer, where his toys were kept, to the top drawer, where his pencils and paper, etc., were kept, he proceeded to fasten other toy animals on to the string and to haul these up too. But there was a difference in the way in which he dealt with

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these animals. For one thing, as he put each animal on the string he said, 'And now I will put this shape on to the string.' Also, when I asked him, 'What are you doing, Peter?' he said, 'I'm taking the shapes from the bottom to the top.' These remarks, and the loose way in which he handled the animals, made me realize that for Peter, at this point in the session, the animals were unclassified 'shapes' rather than specific animals. At that time I was not as aware of the importance of autistic children's 'shapes' as I am now. This was one of the sessions that drew together for me the other autistic children's remarks about their 'shapes'. Looking back, I realize that the toy animals were being equated by Peter with the retained faeces his mother had told me about at the end of the session, and that they were being used as 'shape-producers', I realize now that at this stage in the session Peter was resorting to his self-induced 'shapes', just as Tony and Elly did, to calm himself down after a shock. The shock had been his identification with the fallen giraffe as the 'flopped' part of himself. He was trying to 'raise up' both his shapes and himself into a better frame of mind. By the magical act of raising the 'shapes' he was trying to reassure himself that all was well. I did not understand that so well at the time, but I asked him questions to try to clarify what he was doing and then drew his attention to the obvious. Knowing that autistic children tend to equate their body with inanimate objects rather than identifying with people, I asked Peter if the chest of drawers was like his body. He said that it was and, since he had the top and bottom drawers, I suggested that the top one was his head and the bottom one his bottom. I also suggested that the locked drawers in the middle part might be his tummy, to which he replied firmly and dismissively, 'That part is missed out.' Significantly, the middle drawers contained the other chidren's toys and were locked, so he could not touch or handle the contents. In the light of this, I pointed out the obvious fact that if he had no stomach, then his head was not connected to his bottom.

138 AUTISTIC BARRIERS IN NEUROTIC PATIENTS This drew his attention to the lack in his sense of his body 'shape' - his 'felt-self', as Jonathan Miller (1981) has termed it. Whilst Peter was in this state of bodily unintegration, he needed the magical envelopment by his self-induced 'shapes' to seem to hold him together and to reassure him against the everimminent catastrophe of being 'flopped'. His use of the 'shapes' was a kind of rumination in which he chewed the cud of known and familiar shapes. What went in at his mouth came up again unchanged because there was no stomach in which it could be digested. But he was puzzled about how what went in at his mouth as food came out of his bottom as 'poohs'; how and where did the changes take place? Later in the session he stopped taking his magical 'shapes' round and round on a string. He accepted the fact that he had a stomach and that processes of digestion took place there. He obviously felt that the tummy-button buttoned up the stomach and that if that came undone, all sorts of 'monsters', as he called them, would pop out. So his stomach, and indeed any stomach, were frightening places where 'not-me' things, including other children, might pop out to hurt him. As these 'nameless dreads' were 'stomached' in the therapeutic ambience of the session he no longer needed his magical envelopment by 'shapes', and so we could settle down to a discussion of 'growing up' properly. This was concluded when I said that I had turned over his 'shapes' in the stomach of my mind and he had turned over my 'shapes' in his, and something new had come out; to which he had replied, 'I suppose that's thinking', to which I replied somewhat sententiously, 'And you can't touch or handle thoughts.' Is it too far-fetched to think that, during this session, Peter's perseverative ruminations associated with his idiosyncratic 'shapes' had been transformed into 'thoughts', through interplay with another person's 'shapes', which facilitated a process of psychological digestion? The details of how this transformation occurred are somewhat mysterious to me, as also to Peter.

CHILDHOOD PSYCHOPATHOLOGY 139 A helpful way to get in touch with these non-verbal processes is by way of metaphor and allegory. Peter's session, in which he obviously experienced the psychological ambience of the session as a great big stomach in which significant changes took place, reminded me of one of the sequences in a television series called 'Monkey' in which Chinese allegories were brought to the western screen. In this sequence a pale young man of indeterminate sex symbolized 'pure thought'. (This young man's rarefied, innocent look reminded me of an autistic child. He was like a marble statue.) In the allegory, 'pure thought' loses his impulsive monkey and also a strange faceless creature called 'shape-changer'. 'Shape-changer' and the impulsive monkey go into the cavernous belly of the monster who makes earthquakes and volcanoes. The irrepressible monkey and shape-changer are transformed there, presumably because they felt that the volcanic eruptions of their earthshaking passions had been held in experienced containment. Having been through these basic experiences, they were reunited with the young man whose sex seemed more established and whose thought, we can take it, would become more earthily dynamic and less cerebrally 'pure'. Perhaps this allegory expresses better than any words of mine the mysterious transformations that can take place within a context of psychotherapy which understands the violent tempests of human nature, and is realistic about the need to contain them within the transforming crucible of a caring person's mind. It will be obvious that in this work with Peter I was influenced by Bion's (1962a) formulations concerning 'maternal reverie' and its importance in the transformation of what Bion calls 'raw beta elements' by the mother's 'alpha function'. I was also influenced by Segal's (1957) paper on 'symbolic equations'. Autistic shapes and autistic objects are part of the early presymbolic mental phenomena dealt with by these writers. Both Milner and Winnicott were aware of .the importance of providing a containing medium for the expression of these entirely personalized 'shapes', so that violent passions could be

140 AUTISTIC BARRIERS IN NEUROTIC PATIENTS held and expressed through the shared experience of fun and play which had a very serious purpose. Milner (1969), by her 'doodles' and Winnicott (1958), by his use of the 'squiggle game', enabled the child to share his personal shapes so that mental and emotional assimilations could take place. But when he first comes into treatment, a young autistic child does not put pencil to paper, nor does he co-operate and play. An understanding of the function and nature of his inhibiting use of autistic 'shapes' is necessary if he is to be freed from their thrall.

CHAPTER EIGHT

Autistic shapes exemplified in adult psychopathology How tenuous is the nature of an image And in the first place, since primordials be So far beneath our senses ... How nice are the beginnings of all things. Lucretius, Of the Nature of Things* There exist ... primitive somatic ... flowing-over mechanisms which involve cathecting the apparatus of touch and smell, and taste and temperature and also kinaesthetic sense and that of a deep sensibility. Margaret Mahler, 1958

T

his chapter is a revised version of a paper published in the French psychoanalytic journal Topique in May, 1985, pp.9-23. It was also presented at a conference in London arranged by the Los Angeles Continuing Education Seminars in 1985. T h e paper sought to bring further thoughts on autistic shapes and to relate them to a seemingly inaccessible neurotic adult patient.

The nature of autistic shapes As we have seen, autistic shapes are tactile sensation traces which are experienced in a tangible way as diffused swirls of fluids or soft bodily substances. These shapeless shapes, which *I wish to thank Otto Lichtenstein for introducing me to Lucretius, and for suggesting the experiment by which the reader might experience sensation shapes.

142 AUTISTIC BARRIERS IN NEUROTIC PATIENTS have no shared meanings, are pathological manifestations, and are part of the autistic child's relatively undifferentiated sense of 'being'. They are not predominantly visual images, as are the objective geometrical shapes which we all share. Such shapes are inchoate tactile manifestations. Autistic shapes seem to have much in common with the 'tactile hallucinations' described by Piera Aulangier (1985). Indeed, in my earlier paper on autistic shapes (Chapter 7, above), which was written before I knew about Aulangier's work, I suggested that autistic shapes were a kind of 'tactile hallucination'. From her long experience with schizophrenic adult patients, Aulangier differentiates these 'tactile hallucinations' from the more usual auditory and visual schizophrenic hallucinations. She sees 'tactile hallucinations' as preserving the patient's 'existence attribute'. Work with autistic children fully confirms that they a.re reactions to this, the loss of their intrinsic sense of existence being autistic children's greatest dread. Massive tactile sensations prevent threatening things from being experienced. T h u s tactile sensations dominate the world of the autistic child, sight and hearing being subservient to them. Autistic sensation-dominated shapes are experienced on internal and external body surfaces which are not differentiated as outside or inside. They are also experienced on the surfaces of non-bodily objects which may not be clearly distinguished from bodily ones. Let me bring a clinical example of this latter type of activity. It comes from a session which Madame Claude Cauquil presented to me for supervision in Paris in 1984. When Madame Cauquil worked with this five-year-old autistic boy neither she nor her supervisor, Madame Annie Anzieu, knew about my formulations concerning autistic shapes. Madame Cauquil has generously given me permission to use this material.

Clinical material As this was his first session, the mother accompanied Steve into

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the room. When the mother left, Madame Cauquil recorded Steve's reaction to this separation as follows: After the mother left the room, Steve sits facing the window turning his back to me. He drools on the window-pane, and with his fingertips spreads saliva over the surface of the window-pane, forming whorls of spit which invade more and more of the glass until the window-pane becomes opaque, and we are no longer able to see through it. Madame Cauquil continues: 'Since his mother left, the space between Steve and me, and his mother and him, seems to be clogged up. I feel him to be inaccessible to me, wrapped in a wet universe which he himself secretes.' She also says that Steve seems 'glued to the window-pane'. Later she writes: 'Steve discovers the crayons on the table. H e scribbles on a sheet of paper with the same movements as he had used with his saliva.' For many sessions after this, in the words of Madame Cauquil, 'Steve scribbles on the walls and on the floor, making me feel bound by his drawings as if by spiders' webs.'

Discussion of Steve's material T h e foregoing clinical material illustrates Steve's outburst of 'shapes' in the stressful situation of being separated from his mother. T h e 'scribbling' with his spit and with the pencils helped him to cope with the unthinkable rage and panic aroused by finding that his mother was not under his control, and that she could go away and leave him. Older children often manifest such unthinkable turbulence by what is called 'fidgeting'. Such 'scribbling' and 'fidgeting' 'negate'- to use Freud's (1925) word - the mother and the outside world. T h e diffused inchoate whorls of spit and the scribbling distract Steve's attention away from the mother who is not physically connected to him. They prevent him from thinking about that situation. Thus, the 'unthinkable' situation remains 'unthinkable'. Steve is sealed off in his 'wet universe which he himself secretes', as Madame Cauquil so well expresses it. In

144 AUTISTIC BARRIERS IN NEUROTIC PATIENTS this universe he can feel stuck to inanimate objects as a 'mother' which cannot move away from him. T h e shapes made from his spit seem to be exuded from his body like glue to be smeared on to a surface to which he feels 'stuck'. Being stuck to 'something' probably helps him to feel that he is a something and not a nothing. But the 'sticking' is not an attachment or a connection, because there is no space between the child and the object to which he feels 'stuck'. Later, when Steve scribbles on the walls and the floor, Madame Cauquil feels 'bound by his drawings as if by spiders' webs'. This is probably because Steve is trying to treat her as if she is an inanimate object to which he feels stuck so that she cannot move and go away and leave him. Realizing her countertransference feelings helps Madame Cauquil to get free from them. These children have a sort of charm, which, if we are not aware of it, can bind us to them so that we become a 'soft touch' and collude with their autistic shapes, instead of seeing them as impediments to psychological growth and as a negation of life and of human qualities. It is also inaccurate to see these shapes as communications. As Madame Cauquil realizes, they 'clog up' the space which is needed for communication. They are unshared shapes which are idiosyncratic and peculiar to the child alone. Their sole purpose is to enable him to avoid the 'unthinkable' terror of the 'black hole' of disconnection from a mother who, at one time, had been felt to be a part of his body, and who had suddenly been found to be not so (Winnicott, 1958; Tustin, 1972). Steve's material demonstrates the way in which the primordial shape-making propensities of the human mind, which can be so facilitating for psychological growth, have been diverted into manipulative activities which impede such growth. In normal development, these shape-making propensities enable the baby to organize his basic sensuous experiences. From their observation of babies, research psychologists are finding that, in relation to certain important gestalts associated with the mouth, the co-ordination of the

145 modalities of touch and sight normally occurs within the first few days of life. This is a remarkable finding and has been confirmed by several workers (Bower, 1977; Meltzoff and Barton, 1979). The autistic child has remained stuck in a predominantly tactile mode of functioning which does not become differentiated from and co-ordinated with sight and hearing in the normal way. I have come to realize that vision and hearing, as a result of the undue dominance of the sense of touch, become excessively imbued with tactile sensations. Autistic children feel that their eyes are physical instruments to control objects, which seem to stun and transfix people, to 'cut them dead', to black them out of existence, to annihilate them. These are not metaphors to the children; they feel that they actually do such things. Also, if they see something unpleasant, it feels as if their eyes are being struck by a painful object, while a loud noise can be felt as a blow on the ear. Such painful happenings are counteracted by turning to the comfort of self-induced shapes. These reinforce the unduly tactile nature of the child's experience. This means that tactile bodily feelings become unduly important to him, as does the physical presence of objects. People are experienced as particularly contrary objects which get out of his control; window-panes and suchlike inanimate objects are felt to be much more satisfactory. This results in a negation of the mother and her human qualities. She is replaced by tactile shapes which are under the child's tyrannical control. These are not a substitute for the mother which enables the child to wait for her return. They are a tangible replacement for her which blocks imaginative representation. ADULT PSYCHOPATHOLOGY

Autistic shapes It is difficult to know what shapes the autistic child makes in secret from his body substances and their equivalents, but I do know that these secret shapes are ephemeral and changing. As they emerge from their autism, some children become fascinated by geometrical shapes such as squares and triangles.

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One speaking autistic child even spoke of a trapezium. I now want to correct something I said in the previous chapter about autistic shapes. I have come to realize that attention to, and the drawing of, circles sometimes heralds the emergence of the self. Drawing used in this way is not so elemental as the autistic shapes I am discussing here. Eugenio Gaddini, Kate Barrows and Genevieve Haag have all mentioned this aspect to me and have generously given me interesting material about it. T h e autistic child has no sense of being a self, and is cut off from relationships with people. He is in what is virtually an 'objectless state', and demonstrates for us the tragic consequences of such a state. This is in great contrast to the symbiotic or schizophrenic-type children, who feel full of internal objects which have the dramatic interplay with each other which has been described so insightfully by Melanie Klein. Objects with a separate existence and with functions that can be shared with other people are not significant to encapsulated autistic children. Autistic objects, which were discussed in Chapter 6, are not objects in the true sense; they are hard, object-like sensations engendered by grasping an object tightly. They are pseudo-objects in that, like the soft autistic shapes which are engendered by holding an object loosely, they have no existence apart from the child's own manipulations. They do not exist in space and they have no spatial relationships with other objects. They have no shared meanings. They are peculiar and personal to the child alone who, by touching them, brings them into being for his own idiosyncratic purposes. They are inseparable from the sensations they engender. Autistic objects and autistic shapes are like mirages in the desert in that they are unreal manifestations which do not have any reality apart from the child himself. Constant resort to these objects and shapes means that autistic children, instead of having creative internalized experiences with the mother's breast (and all that this implies), have 'object-like' and 'shapelike' tactile sensations on body surjhces. These superficial and

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unreal securities and comforts do not give them fundamental help in times of stress. They merely prevent the child from experiencing and learning from them. It is a truism that, to be able to cope with stress, we have to have bearable experiences of it in order to gain experience in dealing with it. Their sensationdominated avoidance reactions mean that autistic children have missed such learning experiences. I have come to realize that not all autistic shapes are felt to be sticky; some of them are wet and slippery. Such soft and slippery shapes are the autistic child's self-made form of tranquillizer. Unlike autistic objects, whose hard unchanging outlines seem to form a callus over body surfaces, autistic shapes are soft and melting and also fluid and changing. T h e fluid shapes seem to caress and stroke the child to calm him down after stressful happenings which have threatened to interrupt his sense of continuous existence. An important situation of stress occurs when the infant becomes aware that he does not control the mother's goings and comings, and that he cannot control what happens in the outside world. Unexpected things can occur. In the previous chapter I brought material from eight-year-old Peter, twelve-year-old Elly and eighteenyear-old Tony to illustrate the fact that autistic shapes of various kinds are engendered to deal with the stressful situation of unventilated tantrums about disappointment. T h e selfinduced autistic shapes of Steve, Peter, Elly and Tony were calming agents on the ruffled surface of their stream of consciousness. They poured oil on troubled waters. Elly's behaviour also demonstrated that states of ecstasy* were as unbearable as states of tantrum. For her, the moon was such an aesthetic experience that she could not say the word 'moon', it touched her too deeply. T h e moon was number 7, *In connection with the unbearable nature of states of ecstasy, James Greene has sent me the following verse from Pericles: Lest this great sea of joys rushing upon me O'erbear the shores of my mortality, And drown me with their sweetness.

148 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S which was a very special number. We have seen that numbers, for Elly, were shape-producers. Such shapes enabled her to control her unutterable ecstasies as well as her unthinkable tantrums. But they cut her off from her caring family, who could have helped her to develop less rigid and mechanical means of control. Resort to autistic shapes would seem to begin in earliest infancy. The children experienced stress at a time when their neuromental apparatus (their elemental ego) was insufficiently developed to cope with the strain, and in a family situation which, at that particular time, was not adequate to cope with it either. Autistic shapes are pre-image, pre-object and thus presymbolic. From her long experience with autistic children, Margaret Mahler (1958) writes as follows: 'In order to understand normal as well as disturbed feelings of identity, we have to go back not only to the preverbal stage, but all the way to a stage before images were formed ... we need to go back to primitive modalities of perception .' . In the terms of this chapter these 'primitive modalities of perception' are tactile sensation shapes, both normal and pathological. In the quotation at the head of this paper, Lucretius uses the term 'primordials' for the normal manifestations of these primitive modes of perception. Let us now discuss such normal 'primordials' before discussing further the pathological aberrations of them which have been called autistic shapes.

..

Normal primordial shapes As mentioned earlier, Tom Bower (1977) and Meltzoff and Barton (1979) have shown that in normal infants, in relation to certain psychobiological gestalts which have survival value, tactile and visual perceptions become co-ordinated in the first few days of life. Thus it is tenable that, as tactile and olfactory perceptions become associated with the more long-distance ones of sight and hearing, awareness of objects located in space will develop, and the infant will have increasing moments of

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awareness that his body is differentiated from that of his mother. These moments will come and go in a fleeting sort of way, perhaps even from the early days of life. It is important that the very young infant is helped to bear the stress of these moments of differentiated awareness of his bodily separateness from the mother by the establishment of mental connections with her. Gradually, with this support, as the infant's neuromental organization becomes more integrated, and as he internalizes a body of satisfying experiences with a responsive mother, he will become more able to bear the times when he is aware of his lack of bodily connection with her. T o offset the threat of the 'hole' of her absence, there will be memories - tactile, olfactory, auditory and visual - of close experiences with her. These prevent her absence from becoming a 'black hole' full of unventilated panic, rage and despair. Provided that the times of separation do not go on for too long, 'basic trust' (in Erikson's sense) will develop in unison with hope, its faithful ally. Thus, a capacity for prediction and a belief in the continuity of objects in space will develop. In the long run, these intangibles will be far more reassuring than the secret superficial comforts of selfinduced tactile sensation shapes. Normal 'primordial' shapes would seem to spring from autosensuous rhythms and responses at the root of our'being'. They would seem to affect the individual's capacity for empathy, and thus for relationships with people. These will lead on to the apprehension of objects as objects in their own right, which exist apart from the child and which have .distinguishing shapes. From these shapes, differentiated images of these objects will be formed and imaginations about them developed. Peter, the autistic boy mentioned earlier, had a session in which he talked abhut his 'shapes'. He ended our discussion of them by saying, 'I suppose that's thinking.' By the trans-forming influence of therapeutic trans-actions, his pathological autistic shapes had become normal ones which facilitated the development of 'thinking', for which imagination is a pre-

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requisite. Let us now return to our discussion of aberrant shapes and use our understanding of them to enter the world of the autistic child.

The autistic child's world Autistic shapes and autistic objects have helped the child to survive the shock of meeting what seems to him to be the stubborn intractability of the outside world. But to us, the autistic child's predominantly tactile world of unshared shapes and unshared objects will seem a very strange one. Only what is tangible and manipulable will seem real. T h e long-distance modalities of sight and sound will be overridden by the predominance of tactile sensations. T h e lack of supplementation and elaboration of tactile percepts by an adequate use of sight and sound means that such a child does not form an effective representation of the outside world which he can share with us. His world is relatively devoid of space because threatening gaps are closed by sticking to surfaces. T h e play of a recovering child in therapy, beginning to experience space, is often characterized by his saying that he is in a 'space capsule'. This is to protect him from the horrors associated with space. Prior to his being able to play in this way, and so to express his fears about space, the autistic child's world has been mainly one of flat, two-dimensional surfaces with the black pit lurking beneath them. T o avoid falling into this black pit, tactile autistic Shapes and autistic objects have dominated his awareness. T h e soft sensation shapes have calmed his terrors and the hard sensation objects have made him feel invulnerable, but they have massively inhibited his psychological development. Let us now relate our understanding of the autistic child's use of sensation shapes to a neurotic adult patient whose awareness was dominated by them. Autistic shapes in a neurotic adult patient Mary was in her late twenties. Her therapist came to me for supervision because she was finding it difficult to get in touch

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with this patient. From our work together it became clear that Mary had a hidden capsule of autism which was interfering with her relationships with people and also affecting her work. A piece of personal history which is relevant to this session is that her mother had told Mary that, after she was born, Mary had cried a great deal and that she (mother) had not known how to comfort her. There is also evidence that Mary's mother was a somewhat immature person who, in her mind, had conceived of the baby she had conceived in her body as a kind of doll. T h u s she had been bewildered and shocked when she was confronted with a real live human baby who cried a great deal. Mother and child were not able to heal each other from the primary shock of bodily separateness.

The session Mary began by saying that over the weekend she had been in her withdrawn state again. She went on to say that there was a woman who would not leave her alone and wanted to know what was worrying her. She had told her that she was worried about her job and about moving house, but this was not true. These things did not worry her at all; she was worried about deeper things, but she could not tell this woman. (Here I think we see the conflict that Mary is in. She has deep things which worry her, but she cannot tell her therapist about them because, in the transference, the therapist is experienced as the mother of her infancy who could not comfort her.) After a pause, Mary went on to say that she was thinking about fishes. She said that it was the sensation of them - their suppleness and smoothness. It filled her whole mind. It was not so much the fish, but their wet and slippery shapes. Mary then went on to talk about a male friend who would catch fish and cut them open before they were dead. This meant that you could see their hearts beating. She was always very upset when he did this, as if it were being done to her. (Here we see another reason for Mary's fear of the therapist getting in touch with her. I n infancy she had felt 'cut to the

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heart'. She feared that this vulnerable, deeply hurt part of her would be exposed. In a previous session, before coming into the consulting-room, Mary had thought that the therapist was waiting for her with a knife. She had also talked about a badly stitched-up wound. The therapist had understood that in the core of her being, Mary felt that she had a wound that she feared would be reopened by the therapy. In later sessions, we see that this patient had been afraid to have a 'heart' - that is, to experience deep human emotions. Instead she had sensation shapes.) In this session Mary went on to say that she did not know why, but she was going on thinking about shapes, 'not exactly thinking about them but feeling them'. She said that she did this a lot. As a child, in her hometown, she would watch the fish being unloaded from the boats. There would be a big silvery stream of fish. It was a fluid succession of slippery shapes. They seemed to fill the whole world. 'I can feel them nowllshe said. (These patients are always having to 'lick' their own 'wounds'. The 'licking' is experienced as a fluid succession of slippery shapes. These give Mary the comfort the mother was not able to give her, and that, in the transference, she feels the therapist is not able to give her. This was, in fact, far from being the case; the therapist struggled valiantly to be in touch with Mary, but constantly felt she was being made into a 'non-person'. Taking the step of coming to me for supervision was evidence of her care and concern for this patient. Mary's self-engendered slippery shapes soothe and anoint the wound of disconnection from her mother - from her 'hometown' - but they cut her off from relating to the therapist in a deep way, and from deep relationships with people.) Mary's last association in this session showed how much she wanted to change. It also brought some hopefulness that she might be able to do so. Mary said that when she did underwater diving, she used to see the fish slipping into holes and crevices and was always surprised when they came out again head first, because there did not seem room for them to turn round.

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(This is a very condensed association in which Mary seems to be seeing the dangers of her restricted way of life. She is realizing that she may be immured there forever and never be able to escape. She is realizing that 'holing' herself up in an elemental world of self-engendered shapes is dangerous; she may never be able 'to turn round' to live in the ordinary world of objects and people..Although this everyday world is a less controllable world than her world of fluid, slippery shapes, nevertheless she wants to be 'born' into it. The association expresses hope that she may achieve this, for the fishes turn round and reappear from their holes and crevices.) We hope that this will be fulfilled, and that Mary will find that co-operative experiences with tier therapist are more healing than this self-anointing by slippery shapes. Conclusion This chapter has suggested that, like autistic objects, autistic shapes are psychophysical reactions to wounds and hurts which need to be healed by reciprocal interactions with other human beings. Insights into the functions which such manipulations have for the patient promise to open the closed doors of autistic states in both children and adults. In doing this, we are working with something within the patient who, in the words of G.K. Chesterton, is saying, If only I could find the door, If only I were born. It has been my experience that insights such as have been outlined here can enable the therapist to enter the enclosed and secretive world of such patients with respect and compassion, to help them to find the door so that they are released from their solitary confinement and are 'born' as more fully functioning human beings, who can have deep and enriching relationships with other people, and also with themselves. But first of all they must be freed from the terrors against which the sensation objects and the sensation shapes have been a protection.

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Further thoughts about autistic shapes and psychogenic autism I have come to realize that one source of autistic shapes comes from the fact that autistic children do not look directly at people, but take in a great deal by peripheral vision. (Witness Stephen, described in Chapter 1.) This over-developed fringe awareness means that fringe shapes are formed which can never be clearly focused and which constantly elude the children. Austistic children show that they are constantly tantalized by such elusive, self-generated shapes. This increases their discontent. Also, in the end, such shapes are not tranquillizing but tantalizing. Such peripheral shapes also impede the attachment to the mother, which is fostered by looking at her face, especially at her eyes. As a result of the tantrums of panic and rage that she was not a part of their body that they could take for granted, the children have turned away from the mother and become frightened of her eyes. This separateness had been forced upon their attention before they were ready for it. I n Winnicott's terms it 'impinged'; they did not find it out for themselves in their own time, when they were ready for it. This was painful beyond all bearing. They had swerved away from the pain, and from the mother who was the source of it. They stopped looking at her and at other people, and attended instead to the fringe shapes they could make by looking out of the corners of their eyes. These brought some sort of order into their bewildering world, but like will-o'-the-wisps, these sidelong shapes eventually isolated them in immobilizing bogs, cut off from contact with other human beings. Psychogenic arrtism Daphne Nash, a specialist in ancient history who works in the Ashmolean Museum in Oxford, has told me of a whole culture which seems to have been based on elusive, half-formed,

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unclearly focused shapes. This is the culture of the ancient Celts, which she has studied intensively. In a personal communication she has written as follows: T h e ancient Celts' tendency to talk in riddles may have some connection with their allusive (and sometimes positively fragmented) style of design on metalwork; animals and faces are suggested rather than depicted, animate forms are disjointed; circle-based motifs can suddenly look like something else (e.g., a face) and then you lose it again. Old Irish has no words for 'yes' and 'no', only affirmativelnegative paraphrases. Curiously, traditional Irish music almost never has a rounding-off phrase at the end of a piece. You don't know it is going to end until it stops dead. (As if they had never learned to deal with endings.) With well documented evidence she relates this to what can be found out about the ancient Celts' childrearing methods. I n these, from an early age, children were fostered, both boys and girls being sent to different families to reinforce social ties amongst the families concerned. T h e children seemed to be used in terms of the needs of society rather than their own, in order to make social connections which were in constant danger of breaking down. Miss Nash instances that some authorities think that noble children could have had twenty-eight such fosterages before reaching adulthood. Not surprisingly, their stories are often concerned with disastrous separation experiences. Of course, autistic children have not usually undergone actual separation experiences but they have undergone psychological separations. T h e sort of world in which they live has some striking similarities with that of the ancient Celts. Like the Celts who would even go naked into battle, autistic children are foolhardy about realistic dangers and yet, like the Celts, they are in the grip of illusory dangers. For example, the ancient Celts lived in mortal dread that the sky would fall down upon them; similarly, many autistic children are terrified that

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the ceiling may come down upon their heads. This is in marked contrast to the feelings of invulnerability engendered by their use of autistic objects. These seem to serve a similar purpose to what Miss Nash calls the Celts' 'personal and idiosyncratic taboos to protect them from catastrophe'. She makes an interesting comparison between the ancient Celtic outlook and that of the Homeric Greeks. Catastrophe did not just descend upon the Greeks, as it did with the ancient Celts; it was the result of some wrongdoing. T h e mother of Achilles did magic for him, whereas the Celts protected themselves by their own idiosyncratic magic, as do the autistic children. As in the world of autistic children, so in the world of the Celts nothing could be relied upon. There is much material in their stories about mists and ever-changing, elusive shapes. It was a treacherous and dangerous world in which there was little they could be sure about. It seems feasible that their constant experience of being uprooted from their home base had much to do with it. The mother of an autistic child who kept wandering away once said to me, 'She seems to have no homing instinct.' All autistic children seem to lack this sense. They do not feel that they belong anywhere. T h e trouble with psychogenic autism is that once it has started it easily becomes a rootless, empty way of life, kept going by endless manipulations. Used in a massive way, it leads to a devious psychopathic character and to a devious psychopathic culture. I am coming to the conclusion that many of us - some more so than others - have a bit of psychogenic autism which has shied away from the pains and difficulties of relating to other human beings, and has resorted to devious and manipulative means to avoid these pains. We erect barriers to prevent it from contaminating the rest of our personality, and try to avoid being aware of it.

CHAPTER .V/,VE

Shapes associated with emergence from psychogenic autism Here we go r a n d the prickly pear Prickly pear prickly pear Between the idea And the reality Between the motion And the act Falls the Shadow Between the conception And the creation Between the emotion And the response Falls the shadow. T.S. Eliot, 'The Hollow Men', Collected Poems

riends and colleagues who had either heard or read the papers on which Chapters 7 and 8 were based kindly sent me observations concerning another category of elemental shape. This, I realized, needed to be distinguished from autistic shapes. In this chapter these elemental, nonautistic shapes are distinguished from autistic ones, and the significance of their emergence and the part they play in psychotherapy are discussed. First of all, however, let me present to you the observations which stimulated the thoughts embodied in this chapter.

F

The observations Several colleagues, amongst whom are D r Genevieve Haag and the late D r Eugenio Gaddini, wrote to me associating the circle with the emergence of individual identity. In particular, Kate Barrows sent me an interesting observation which indicates that

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a mother and her child intuitively i~nderstoodthat the drawing of an intact circle implied this. Here is her observation.

Obsemation 1 'I wondered about the connection between shapes for the autistic child and shapes for other children. I have always been impressed by how important some kind of a circle - drawn by the child - is, to the child and the parents. I have tended to think of it as connected to the child apprehending something as separate and complete -whether you call it a breast, an object or what have you. It seems, in some way, to show that the child has an independent mind, however fleeting this may seem, and even if the child follows u p the shape with scribbles as before ... 'I had a clinical experience which gave form to my longstanding feeling about this shape. It was an assessment interview, at the hospital where I work, with a little girl of five and her very disturbed, sometimes psychotic, sometimes almost catatonic, sometimes coping mother. T h e child was in a day unit with the mother and was being assessed for individual psychotherapy. I saw them together as neither seemed able to separate. T h e child was withdrawn and scared and spoke in a blurred way, omitting many consonants. At some point in the meeting, she was drawing or rather scribbling, and I said something (I can't remember what) about her feelings, perhaps something to do with whether mummy and I could stand them. She responded by drawing a definite circle. She then looked afraid and her mother said, "It's the first proper shape she's ever done," and burst into sobs. T h e little girl stopped drawing and went to play with the dolls. I talked of their fear of the child being herself. I thought that this sequence showed the mother and child's fear of the child being herself - having a clear outline - seeing the mother clearly.' Obserrration2 'A four-year-old symbiotic boy whom I will call Sam, when asked by his rnother why he sucked the piece of shawl which he always carried around with him, replied,

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"Because it makes a nice shape." When asked what shape it made, he said "a circle". He went on to say that sucking his thumb made "a triangle". He didn't like this, he said, "because of the sharp points".'

Observation 3 'At a certain stage in treatment Mary, the neurotic adult patient with marked encapsulating features [whose autistic shapes were discussed in Chapter 81 and whose mother could not bear her screaming as an infant, once complained to her therapist that she had a scream "at the centre of her being in the shape of a triangle". Such patients often make picturesque remarks of this kind. We may feel that they are not worthy of our serious attention, but since what they say seems very important to them, I think that we should not brush them aside. This patient went on to say, "Scratch the surface and there's nothing but blackness."' Observation 4 Another interesting observation was sent to me by Mrs Dilys Daws, who wrote as follows: 'I thought you might like a little clinical anecdote about "shapes" (not autistic). I have been seeing a disturbed little girl of seven years of age, once weekly. Her family were unable to bring her more often and it was very frustrating. She behaved delightfully with me. I knew how appalling she was at home and suspected that she would be different with me if I could see her more frequently. Finally, we arranged an escort and transport for a second session. She came to the first of these and was irritable with me throughout. Near the end she complained that I had made the "wrong shape" of some plasticine we were moulding. I said I thought that she was telling me that the whole thing of coming to see me today was "the wrong shape", that is, coming to see me in a taxi from school, a lady escort instead of her parents, a different time to see me, different people in the waiting-room, etc., etc. She agreed with enthusiasm and has been bringing her dissatisfactions to me ever since. '

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Discussion of non-azrtistic shapes Autistic shapes follow each other in rapid, slippery succession, so that they are virtually indistinguishable one from the other. This, and the fact that they are unshareable with other people, means that they are unclassifiable. This is the major difference between autistic shapes and those described in the observations presented here. We would classify the ones described in Observations 1, 2 and 3 as geometrical shapes. Dilys Daws' patient classified shapes as either 'right' or 'wrong', that is, in terms of whether they were 'nice' or 'nasty'. They were classified in terms of her preferences. In the bland state of autism even such simple distinctions are not made. Everything is muted and flat. T h e undifferentiated autistic shapes are aberrant modes of patterning sensuous experiences; they are ineffectual so far as effective functioning goes. Classz$able, non-autistic shapes usher in a very different state of mind. The mother of Mrs Barrows' patient referred to the circle which her daughter had drawn as a 'proper shape', that is, it was a classified shape. It was an identifiable shape of a specific kind which could even have a commonly agreed name. Such an intact circle is very different from the rounded shapes which occur in autistic children's random scribbling, or the shapes they make from bubbles or whorls of spit from their mouth, or gas from their bottom. Fabricated from their bodily sensations and from their body stuff, these latter shapes are autistic reactions which seem to bring into being an ever-present, infinitely controllable 'mother'. But this is an artificial 'mother'. These autistic fabrications prevent their becoming aware of the actual mother. T h e circle indicates a movement towards a more realistic perception of the mother, as being separate and different from themselves. This acknowledgement of the actual situation in relation to the mother may take place for only a fleeting moment, as in Mrs Barrows' observation, but, as she so insightfully realized, it is a significant moment. Just as the circle has distinct and definite outlines, so the emergent in-

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dividual begins to feel - perhaps at first only momentarily - that (s)he has distinct body boundaries. These distinct body boundaries indicate an inside space, they are not just edgesfrom zuhich a swface is implied. Clinical work suggests that a shape which has an inside space, and which can seem to be a 'container', emerges when patients are beginning to feel held in a caring person's awareness. They feel less in danger of spilling away and being 'gone'. They have a sense of existence and are beginning to have a distinguishable identity. Being aware of an inside space also suggests that there is the possibility of having an inner life. At first this is conceived in terms of those events which go on in that mysterious stomach from which attention has previously been averted. As was shown in Chapter 7, the autistic child is not aware of the fact that he has a stomach. The emergence of a kind of 'stomachmind' is an important first step in cognitive and emotional development. Fantasies, memories and imagination of a primitive kind become possible. The emergence of shareable, classifiable shapes is part of this forward movement. They indicate the development of somewhat more realistic perceptions. Such shapes are part of the mental furniture of all human beings and so they can promote communications and the extension of perceptions. A11 the classifiable shapes of the observations presented, except those of Dilys Daws' patient, were geometrical shapes (although I suspect that this patient may have been experiencing the 'wrong shape' in something like the geometrical form of 'a square peg in a round .hole9).Let me now discuss geometrical and other types of elementary classifiable shapes.

Geometrical shapes There are two simple classes of geometrical shapes: the closed, smooth curved kind of shapes, of which the circle is the prime example; and shapes with straight lines and sharp corners, of which the triangle is the most elementary. T h e circle and the triangle are the two most

162 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S elementary forms there are. Two straight lines cannot make a geometrical shape; but three lines appropriately placed can make a triangle; and a curved line whose end exactly meets its beginning makes an intact circle. (It is interesting that if a curved line is drawn around the outside of a triangle, connecting together the three points, it makes a circle.) I have come to realize that innate shape-making predispositions play an important part in affecting how we cast our thoughts. I have also realized that these shape-making predispositions provide the means whereby 'me'-sensations can be changed into perceptions of the 'not-me' outside world. Thusgeometrical shapes specifically pattern sensations arising from touch and sight into percepts and concepts related to the properties of space.

Musical shapes These pattern the individual notes that make u p the sensation of sound into those percepts and concepts which are particularly related to the dimension of time. This means that the notes can be experienced as following one another in an ordered sequence so that there is not a hotchpotch of notes, one on top of the other. Speech seems to be a specific kind of musical shape which, like all musical shapes, has amplitude as well as shape. Patients emerging from autistic states are particularly sensitive to tones of voice, and shrink away from harsh and loud tones. This is exemplified by Daisy, a post-autistic child described in Chapter 10. Also, Sydney Klein (1980) mentions the preoccupation of such patients 'with the analyst's tone of voice or facial expression, irrespective of the content of the interpretation'. Thus, as is characteristic of autistic functioning, superficial and surface phenomena are attended to, rather than inner meanings: it is the sound of words rather than their meaning which is important. There are also aesthetic shapes which influence our conceptions of beauty and ugliness. However, the constitutional endowment of the individual would seem to determine which mode of patterning sensuous experience is used most. Aesthetic, musical and geometrical shapes soon become

163 differentiated into the basic categories of 'nice' and 'nasty' (pleasurable and unpleasurable). I n terms of geometrical shapes, the observations presented imply that shapes arising from a closed, curved, continuous line - such as the circle -are 'nice', while angular, sharp-pointed ones - such as the triangle are 'nasty'. It is essential to ongoing psychic development that the sharp, angular experiences, and their musical and aesthetic equivalents such as discord and ugliness, should not be screamed, sneezed or evacuated into a void. They need to be 'caught' and held by an attentive and receptive caregiver. Mary's mother could not bear her screaming; the mother of Daisy, who is to be discussed in Chapter 10, could not bear her 'dirty nappies'. I well remember the sad mother of an autistic child who described with great honesty her post-natal depression after the birth of this particular child. She described how she experienced herself as a 'non-person', and how she would hide the baby's dirty nappies under the bed, because she felt so disgusted by them and could not face washing them. The infants are also confronted with the discrepancy between their inbuilt sensuous expectations and what is actually forthcoming. T o get away from this disappointment and their reaction to it, they also react in such a way as to become a 'non-person'. In psychotherapeutic treatment, we encounter anguished states as such patients emerge from their encapsulation. These are reactions to the sharp, angular, discordant shapes which were experienced before they could bear them. In the poem presented at the head of this chapter, T.S. Eliot called them 'the prickly pear', and described so well the after-effects of this encounter. This unpleasant experience has aroused a profound sulk, which Eliot calls the 'shadow'. This sulk of disappointment this umbrage - which comes between 'the idea and the reality' is the result of the discrepancy between what was expected and what actually occurred. For all of us, there is some inevitable disappointment of the inbuilt expectations we bring into this world. (The Garden of Eden story is a metaphor for this.) But EMERGENCE FROM PSYCHOGENIC AUTISM

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for some infants, for various reasons which will be discussed later in the book, this disillusionment has been crippling. In an insufficiently mature psychic state, they have been called upon to bear the discrepancy between what is, and what they would like it to be. Of course, we are talking about a situation which has been known from time immemorial. In psychoanalytic terms, we call it the dawning of the reality principle. Patients crippled by autism have met hard, angular reality in a neuromental state in which they could not cope with it.

The dawning of the reality principle When sensation shapes become related to inbuilt constructs which are shared with other people, percepts and concepts come into being. This is the beginning of the world of common sense. In normal development, this begins in the nursing situation when the whole of the suckling experience, such as the sensations in the mouth, the shining eyes and the encircling arms, are all married together into the perception and conception of 'mother'. T h e circle seems to be a preverbal way of expressing the experience of feeling held - ringed around - by a nurturing ambience which circulates around the infant as a central figure. T h e circle is an expression of this feeling of everlasting containment and contentment. T h e angular figure with sharp points typifies the disturbance of this circular situation, which had been felt to be endless. A situation in which, as T.S. Eliot says in another poem not quoted here, 'the end is the beginning'. Angular shapes with sharp corners are much less satisfactory. One reason for this is that the two-line (two-body) situation of mother and baby exclusively together is disturbed by other lines (other bodies) coming into awareness. Another reason is that the place where the separate lines join brings in the notion of endings, and of changing direction in a sudden and acute way. It typifies the dawning of awareness that sensuous experience with the mother is not continuous and unbroken, but is one in which there are jolts and breaks and changes; she comes and she goes in a quite unnerving fashion.

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All this has been smoothed over by the autism, to be reencountered as the autism begins to crack. In Sam's case the distressing triangle, and all that it implies, is evoked by sucking his thumb which has a hard bit - the thumbnail. This interrupts the smooth circle of his sucking mouth. But for him this horrible experience is balanced by the unbroken circle he gets from his soft piece of shawl, which he can mould and shape as he pleases. Mary is finding her encounter with the triangle to be excruciating. Her sulky umbrage about the discrepancy between the 'birthright' her inbuilt 'blueprints' had led her to expect, and what she had actually had, was being re-evoked in the infantile transference to her psychotherapist. T h e trouble with Mary is that she felt that, in the screaming of her infancy, she had exploded away the 'circle' - the encircling arms of her mother, and all that was associated with these. She is repeating this experience in the infantile transference to the therapist. When the primal umbrage is as 'crow-black' as Mary's seems to be, it presents a serious barrier to psychoanalytic work. As patients emerge from their autistic encapsulation, they encounter the black despair which has been silenced by their autistic devices. For various reasons, which have been discussed in other chapters, the infant sorrow described by Blake has been excruciating for such patients. They come upon the scream at the centre of their being.* As they emerge from autism, such children often screw up the picture they have drawn because it does not reproduce the picture they had in their mind. I n T.S. Eliot's terms, the shadow of their massive sulk has come between the 'conception and the creation'. As psychotherapists it behoves us to be as closely in touch with the nature of our patient's experiences as we can be. This is particularly difficult if we are dealing with preverbal ones. It has seemed to me that these insights into the shape-making modes of the human mind can help us to talk to certain patients, *I should make clear that I am not associating myself with treatments which concentrate on the 'primal scream' and with 'birthing' techniques.

166 AUTISTIC BARRIERS IN NEUROTIC PATIENTS as they emerge from the encapsulation of autistic states, in a way whicheis meaningful to them. This is particularly the case with autistic children who are more closely in touch with elemental modes of functioning, and also more totally in their grip. Neurotic patients who, in a part of their personality, have not been so cut off from outside experiences as the autistic children have been can call upon their image-making resources to tell us about their autistic experiences, as did the adult patient whose dreams were quoted in Chapter 1. However, it is only when they are on the point of emerging, or have emerged from autism, that patients can tell us what it was like. So our evidence comes from hindsight. As these patients begin to bear the gap of separateness between the mother's body and their own (in the infantile transference, the gap between the therapist and themselves), they encounter the fact of space in a particularly excruciating way. Prior to this, they have been protected from this painful awareness by the strategies of the autism. Geometrical shapes help them to pattern their emerging sensation experiences of space. These shapes swim into the child's awareness unbidden. They are not the effect of teaching. They seem to arise, as do musical and aesthetic shapes, from basic inbuilt neuromental structures which elsewhere I have called 'innate forms' (Tustin, 1972). In relation to language, Noam Chomsky (1972) has written about the innate 'deep structures' which programme the child's use of language. 'Innate forms' seem to be the basic elements from which thinking and feeling develop. They are not archetypes as described by Jung, nor are they 'unconscious phantasies' as described by Melanie Klein, although they may be basic elements for these formations. Innate f o w s These 'innate forms' are seen in 'pure' form that is, relatively unmodified by outside experiences - in autistic children who are emerging from encapsulation. This is due to the fact that the children have been relatively cut off from outside experiences, and 'innate forms' are all that they have

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had to pattern an influx of sensations which otherwise would have seemed to be simultaneous, one on top of the other. Geometrical shapes, which are a specific type of 'innate form', help to order the sensations of touch and sight in terms of the space encountered as separateness from the mother is acknowledged. Otherwise the space would have been experienced as a formless void. However, these geometrical shapes, which the children talk about or draw, do not seem to be metaphors in quite the same way as Eliot's 'prickly pear'. For patients emerging from autism, they seem to be the primary moulds in which the early experience was cast. Clinical work with autistic children indicates that psychic development has been arrested at this early, basic level of 'innate forms'. Thus it has seemed important to know some of the detail of this early experience, rather than to talk in global terms about 'unresponsive mothers' and 'unresponsive babies'. If we are to give effective psychotherapy we need to understand how our patients' minds work. T h e appearance of geometrical forms seems to be an important step in psychic development. Such forms appear at a critical point in the psychotherapeutic process, when the patient is struggling out of the 'tomb-womb' of psychogenic autism to achieve what we, metaphorically, call 'psychic birth'. They seem to be the harbingers of a move into sense experiences that are shared in common with other human beings. But at first the forms are experienced in a preternaturally hypersensitized way, due to the patients' having been in the hothouse of the autistic capsule. This means that opposites are experienced in an extreme way: for example, there is the beloved 'circle' and the hated 'triangle'. It is felt that they must be kept apart from each other, or else the circle will be destroyed. Through the infantile transference to the therapist such patients are gradually enabled to live through and to integrate these extreme states, so that unstable, up-and-down reactions become modified. (This is well illustrated by the graph on psychotherapy with an adolescent girl suffering from anorexia nervosa, described in Chapter 14.)

168 AUTISTIC BARRIERS IN NEUROTIC PATIENTS A brief word now needs to be said about the state into which such patients move as they abandon their autism.

After autism T h e psychic situation into which such patients emerge from their autism has been described by Margaret Mahler as a symbiosis between child and mother (therapist and patient). In this state processes of projective identification, as described by Melanie Klein and elaborated by Bion, become very active. T h e state is also associated with Winnicott's transitional object, as witness Sam's piece of shawl. In this state some degree of co-operation has been established; but it can be an entangling state too, and this has to be modified by the psychotherapy. As Sydney Klein says, neurotic patients with a capsule of autism manifest 'a rather desperate and tenacious clinging to the analyst as the sole source of life ...' (1980). T h e modification of this state is the theme of the penultimate chapter of this book. Conclusion Inevitably we come to a point beyond which our understanding of these elemental situations cannot go. Ultimately, it is beyond the power of mind to study itself, or to express non-verbal mental experiences in words. When writing about them, we are constantly haunted by the discrepancy between what we can intuitively apprehend, and what we can manage to express. But we are driven to go on trying, even though we know that the only certain knowledge is that we can never know 'ultimate reality'. We have to accept being surrounded by mystery. It is the standpoint from which this book has been written. T h e autistic child and the autistic part in all of us hanker after certainty, after freedom from doubt, after complete knowledge, after unalloyed satisfaction. T h e hard fact that this is unattainable is the sharp rock upon which psychogenic autistic patients' ongoing psychic development has foundered. Their emotional and cognitive development has been crippled by the umbrage aroused by it. It is important that we should be

169 alongside such patients, and able 'to talk them through,' this painful but inevitable situation of disillusionment in a way which is meaningful to them. For this reason I feel grateful to the friends and colleagues who sent me the observations quoted at the beginning of this chapter. They have made me look at old truths with fresh eyes. Also, they have suggested a way of talking to patients in terms which are consonant with their preverbal, shape-making experiences. And now, a final word. I n this process of unearthing the basic elements of human functioning, it has seemed important that we should be held by the integrated aesthetic patterns that man has evolved for this purpose. T h u s poetry has seemed to be a necessary part of the exposition. Our aim in working with unintegrated or disintegrated patients who have swung out of human care and 'holding' is to help them to leave their idiosyncratic pseudo-creativity, and to turn to the more authentic shared creative influences by which they are surrounded. Our own use of such influences will increase our therapeutic capacity to help them to do so. EhIERCENCE FROM PSYCHOGENIC AUTIShI

CHAPTER TEN

A glimpse into the world of an autistic child Be near me when my light is low, When the blood creeps, and the nerves prick And tingle; and the heart is sick, And all the wheels of Being slow. Be near me when the sensuous frame Is rack'd with pangs that conquer trust; And Time, a maniac scattering dust, And Life, a Fury slinging flame. Tennyson, In Memoriam, XLIX

he first part of this book began with a description of the external appearance and behaviour of psychogenic autistic children. Let us now end it by having a deeper look into the world in which such children live. This will be a preparation for recognizing the autistic behaviour of the neurotic patients whom we shall meet in Part Two. Daisy, the post-autistic patient to be discussed in this chapter, could speak, so she was able to put into words some of the primitive mental states in which such children live. These states have had to be inferred in the non-speaking, autistic children with whom I have worked. Daisy was being treated by D r Enrico Levis from Italy, who discusses his work with me from time to time, and I am grateful to Dr Levis for his permission to use this clinical material.

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Significant features of Daisy's early infancy As is often the case in children with psychogenic rather than organic autism, Daisy's mother had been very depressed when Daisy was born. As the result of this, baby Daisy and her mother had had an unduly close association with each other (it cannot be called a relationship), in which the mother tended to use Daisy to satisfy her own needs rather than satisfying those of her infant. Another significant feature of Daisy's infancy was that the mother had been very disgusted by nappy changing and used to hand the baby over to her mother (Daisy's grandmother) to do this. Clinical material Daisy was an eleven-year-old post-autistic girl who was seen three times a week. At the time of the session reported here in detail, she had been in treatment for five months. Prior to starting treatment with Dr Levis she had been seen by a psychologist for educational therapy, and had learned to read and write in a somewhat confused way. Although Daisy still had marked autistic features, she was more in touch with the terrors which assail autistic children than are those children who are still massively protected from such terrors by their autistic evasive reactions. As you will see, these evasions were being modified. During the first few weeks of Daisy's visits to Dr Levis she was very hyperactive. She then settled down and became much quieter. During this quieter period, she said that she was carrying on 'an investigation of thoughts'. T o do this, Daisy lay mostly on the floor, writing something that she did not want Dr Levis to interrupt until she had reached the bottom of the page. She said, 'I am discharging', by which she meant 'evacuating'. The writing she did was of lists of 'really savage or sad thoughts' which could magically change into 'blissful thoughts', or into 'cover thoughts'. Daisy drew the 'savage thoughts' as zigzag lines which she associated with thunder and lightning. She drew the 'cover thoughts' as a blue blanket; they were also

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called 'blanket thoughts'. Sometimes she drew these 'thoughts' and sometimes she wrote them. In this quieter period Daisy brought a book to her therapy session which was by Professor Resnik, called Person and Psychosis. She had taken this book from her mother. Daisy pointed out to Dr Levis a chapter headed 'Language and communication', subtitled 'Speaking and listening'. She particularly drew his attention to a sentence which read: 'Some qualities of tone, either harsh or rude, are experienced as real threats.' This had been underlined. As agreat secret, Daisy also told Dr Levis that she wanted her parents to give her a 'Luciotta' for Christmas (an electric lamp which gives a small light in children's bedrooms during the night). Daisy said that she wanted this lamp even if it cost hundreds of thousands of lire. T o get it, she said, she was willing to do without many things that she liked; she was willing 'to make sacrifices'.

Thursday 29 November: 23rd week of treatment Dr Levis recorded that Daisy got out of the lift smiling fatuously. Between her teeth she had a plastic straw. Dr Levis welcomed her and led her into the therapy room. In.the room Daisy shook her head to induce what she called 'gesture drawings'. These were drawings which arose from sensations in her body. They were a developed manifestation of the autistic shapes which were described in Chapters 7 and 8. Autistic shapes are calming and comforting, and they also assist in the discharge of body sensations. In terms of my scheme of understanding, the hard plastic straw is an autistic object, that is, an object which stimulates sensations which help the child to feel invulnerable and impenetrable. Autistic objects and autistic shapes are both auto-sensuous fabrications which are associated with and confirm a state in which the child's body feels undifferentiated from that of a very powerful being (not really differentiated as a mother). They are both felt to be ever-present bits of that powerful being which are under their manipulative control. As such, they prevent the

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child from relating to the actual human mother in a normal way. She is either used as an autistic object or as an autistic shape, that is, as an ever-ready part of their body which either calms them down or makes .them feel invulnerable. This means that the children are out of touch with her as a real human being. But at times, Daisy is beginning to feel that she will have to give up these delusory tranquillizers and invulnerabilities, and begin to depend upon and trust a light which is other than her body, and which is real although intangible. Daisy's desire for a 'Luciotta' seems to be similar to the behaviour of normal small babies who will focus on a light and then seem to feel pulled together and safe. However, at the beginning of this session, having just left her mother, and having just entered Dr Levis' room, Daisy needed the plastic straw and the 'gesture drawings'. Dr Levis sat on the couch and Daisy sat there also. She gathered three cushions and bunched them. together on part of the couch as if to protect herself from him. As she took off her shoes, Daisy asked seductively, "Do you know how many lovers I have got, mumfather-doctor?' (Here I think we see that, as well as her autistic objects and autistic shapes, Daisy is marshalling her auto-erotic feelings to help her to deal with excited and frightened feelings about being wih the 'mum-father-doctor'.) When Daisy continued with her seductive questioning, Dr Levis interpreted to her that she felt that she needed a 'Luciotta' so that she was not so afraid. This interpretation was good enough to help Daisy to feel safer. After it, she slipped to the floor and, on her knees, propelled herself to a small table where there were sheets of paper and pencils. She put down the plastic straw, which she had by now transferred from her mouth to het hand, and took two sheets of paper and some crayons. Then she lay on her stomach on the floor and, after writing her name as she had been trained to do at school, she started to draw some birds masses and masses of them. Dr Levis asked her what she was drawing and she answered, 'These are flying thoughtslbirds. Flying faster than light.' Later she said, 'These are invading

174 AUTISTIC BARRIERS IN NEUROTIC PATIENTS thoughts.' Dr Levis has given me translations of what Daisy wrote on the paper. These were: 'Bird-thoughts, invading, flying.' After a while, Daisy handed the sheet of paper to D r Levis. It was completely covered with confusedly interweaving shapes. Still on her knees, Daisy raised herself up to take another sheet of paper. She was uncertain whether to take a larger one or a small one like the one she had just used. She made up her mind to take the smaller one and remarked, 'Some time ago I would have used a lot of superlatives. Now I am content with writing how big they are.' It is characteristic of autistic children that when they begin to speak they like using long words as, for instance, Daisy's use of the word 'superlative'. It seems that Daisy was saying that she could take the smaller piece of paper and did not need to use 'superlatives', because she had been relieved by the 'discharging' she had been able to do with D r Levis. These children feel turgid with accumulated feelings experienced in a sensation way. T h e aggravation and irritation of pent-up feelings would have been the cause of Daisy's hyperactivity when she first came to see Dr Levis. This had now been moderated by his acceptance of her evacuations, and by his attempts to help her to put them into words and then to think about them. Daisy now drew what she called a 'flash', meaning a streak of lightning, and with arrows pointing to the 'flash' indicated that 'flashes' of. lightning were 'savage thoughts'. She had just started writing the first line of 'savage thoughts' when she was startled by hearing her mother walking away down the corridor outside the room. It was as if she had been sunk into her bodily flow and this interrupted it. She said, 'She is leaving', and immediately left an empty space on the sheet of paper on which she was writing. Her 'thereness' had been assailed. As a reaction to this startling interruption, Daisy started to write feverishly as if to be reassured that the flow of her being could still go on. She filled the whole sheet of paper, even filling in the space she had left empty. She ignored what D r Levis said, as if to shut out any

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further interrruptions to her 'going-on-being'. Dr Levis has given me translations of this disjointed, confused, frenetic writing. On the first sheet of paper, after writing her name, Daisy wrote 'savage thoughts infinite' as a heading. She then wrote what provoked these 'savage thoughts'.

(1) that dangerous things happen to me that people talk in harsh and rude tones. (2) that I find lovers who cry at me to drive me away that I find wrong lovers, because they do me harm that is to say they or other harms that I am hated by people At this stage of the session, although Daisy was still trying to communicate, the flow of her writing was also important in giving her the feeling that life went on in an uninterrupted way. In the sentence 'that is to say they ... or other harms', Daisy indicated that interruptions provoked 'savage thoughts'. After a time the writing did not sufficiently discharge her agitation, and she discharged it by some hyperactive capering about the room. Eventually, however, she calmed down a little as Dr Levis talked to her about how much she wanted him to be a 'luciotta' - a light to lighten her darkness. Following this interpretation, Daisy took another sheet of paper on which, after writing her name as usual, she drew a stylized flat image of an angel with wings, against which she wrote 'blissful thoughts'. It was as if these were to counteract the 'savage thoughts'. Dr Levis' translations of these 'blis-sful thoughts' are as follows: 'blissful thoughts infinite' was the heading. Daisy then wrote what provoked these 'blissful thoughts'. to make the lover fall in love to drive on the highway at full speed to go to Heaven early

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to get presents to have sweet dreams. Daisy also drew some butterflies. These, like the angel, were 'blissful thoughts'. After engendering these 'blissful thoughts', Daisy's agitation subsided and she wrote a somewhat less confused and frantic communication to Dr Levis. In translation it read 'mum-fatherdoctor having that you see it would be beautiful as if I could fly.' You will notice that Daisy wrote 'as if I could fly'. A child in a more total state of autism would have felt that he or she was flying. Daisy was merely wishing that she could do this. As it was near the end of the session, Daisy was probably sensing and reacting to this imminent interruption to her 'going-on-being'. When Dr Levis said that it was time to go, Daisy became very upset and hastily started to draw some birds on the empty space which was left on the sheet of paper she had been using. These heavily drawn birds had a different 'feel' from the lightness and delicacy of the angel and the butterflies. They seemed to block the gap of separateness between her and the powerful 'mum-father-doctor', bodily continuity with whom she felt guaranteed her sense of 'being'. When he seemed to speak in 'harsh and rude tones', that is, when he said things she did not like, it broke Daisy's sense of bodily continuity with him, and she felt reduced to a 'non-being' - to an empty space. Dr Levis talked to her about her attempts to fill the gap of separateness between them. After putting on her shoes Daisy rushed to the bathroom saying, 'I'm thirsty. I'm thirsty.' D r Levis interpreted this as her need to fill up the empty space so that she did not notice the gap of separateness between them. After this interpretation Daisy accepted that it was time to leave. She met her mother, who had brought some bread baked with olives. Daisy took this and ate it voraciously. 'To fill up the hole', as D r Levis said, just as the plastic straw in her mouth had performed this function at the beginning of the session, when she had separated from her mother; one of the uses of autistic

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objects is to seem to block the hole of bodily separateness so that a semblance of bodily continuity can be re-established. It will be clear from this account that the infantile transference was now in operation, and that Daisy was experiencing Dr Levis as a powerful 'mum-father-doctor', continuity with whom ensured her own continuity of being. Without this 'mum-fatherdoctor'- originally the mother's breast, or its substitute, and all that is associated with this experience - Daisy felt that she would cease to exist. Dr Levis recorded that Daisy left with 'a dull and troubled smile'. After a couple of minutes there was a ring at the door. It was Daisy and her mother, who had rung 'by mistake', as mother said, adding, 'We wanted to turn on the light.' It seems that mother, as well as Daisy, feels the need for a 'Luciotta' to protect her from the darkness of the chasm of interrupted continuity with the all-important being who is felt to be the source of power, comfort, security and 'thereness'.

Discussion First of all, I want to say a few words about Daisy's use of the words 'love' and 'thoughts'. It is useful that Daisy lets us into the autistic world through a medium with which we are familiar; but the words often have meanings which are idiosyncratic to herself alone. The teaching she had had before coming to Dr Levis had stimulated her to speak and to 'bark at print', but these words were often used autistically. We need to try to understand what the words meant to Daisy and to be careful not to impose our own more sophisticated meanings upon them. However, I think it is safe to say that from being virtually devoid of emotions and thoughts, Daisy is touching the fringes of such potentialities. At the moment for Daisy, 'love' seems to be getting what she wants in a sensual way, and 'lovers'are those who give her this. Similarly, 'thoughts' are sensations and feelings which are on the verge of becoming 'thoughts'. They are 'protothoughts'.

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They are what Dr Bion has called 'thoughts without a thinker'. Dr Levis had to be the 'thinker' for them until Daisy could 'think' them for herself. She felt turgid with these unthought, unthinkable 'thoughts'. These partook of the nature of bodily evacuations ('discharges', as she called them). Her depressed mother had not been able to tolerate these in either their bodily or mental aspects. By accepting them and trying to understand them Dr Levis was helping Daisy to accept and to come to terms with them. These unbearable 'sensation thoughts' concerned Daisy's infantile feelings about bodily separateness experienced in a state in which the mother and her breast, when lost, seemed to have been an immortal, everlasting 'being'. Prior to its loss, it had been taken for granted as being part of her body. Over-long association with this mother, and the mother's over-supportive attitudes, had confirmed this delusion. Sudden and inevitable awareness of bodily separateness from such a being had seemed to be a catastrophe from which Daisy never recdvered. She had felt denuded of the very thing which made her exist. As an infant, Daisy did not 'think' this as a 'thought'. It was a sensation of loss and lack which has later depicted as a 'hole' or as an empty space. It was experienced as a break in bodily continuity - as what is later called 'death'. Work with autistic children shows that this babyhood experience has had far-reaching and longlasting effects. The actual mother was rejected because she could not satisfy the child's unrealistic expectations of her, although many of these mothers struggle manfully to do so. (This is why the unfounded criticism of them prevalent at one time amongst psychodynamic clinicians was so hurting to them.) Instead of relating to the mother, the child resorts to fabrications such as autistic objects and autistic shapes. The significance of these artefacts to the children is that they feel that they have a tangible bit of an ever-present, everlasting, continuous pseudo-'mother' which obviates the gap of separateness. But these autistic

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practices cut them off from the actual mother and from other human beings, as well as impeding emotional development and effective thinking. Daisy's use of the plastic straw as an autistic object and her use of 'gesture drawings' as autistic shapes illustrate these points. But Daisy was emerging from autism and could talk about it. When the child is in an out-and-out autistic state, he or she is paralysed by it and cannot speak. Daisy can speak and uses the phrases 'savage thoughts', 'sad thoughts' and 'blissful thoughts' for what, in my writings, I have referred to as 'tantrum', 'grief' and 'ecstasy'. A depressed mother whose capacity to bear these extreme states is very restricted cannot help her infant to come to terms with them. Faute de mieux, the infant is driven to develop the autistic reactions that have just been described to protect him or her from unbearable sensations. Daisy refers to these autistic reactions as 'cover thoughts' or 'blanket thoughts'. But Daisy is also beginning to feel that she has to give up these autistic evasions of reality: to make 'sacrifices', as she says - if she is to get the desired 'luciotta'. With the illumination of D r Levis' insights, she is beginning to become conscious of some of the states against which the autism had been a protection. In a confused way, she communicates with Dr Levis about this by writing, drawing and speaking. However, after being startled by the interruption of the sound of her mother leaving, the desire to communicate with him took second place to Daisy's alarmed and frantic need to feel continuous with her 'mum-father-doctor'. As these autistic reactions abated, Daisy was aware that she could not really fly away. (You will remember that she says, 'having that you see it would be beautiful as if I could fly.') When fully immersed in an autistic state, she would not have recognized this as an impossibility. She would have felt that she And flown away from her terror of endings and partings. She might have felt that she was inside the body of the powerful 'mum-father-doctor', or that she was outside her own body, and

180 AUTISTIC BARRIERS IN NEUROTIC PATIENTS so could avoid the bodily separation which meant loss of the sense of 'being' which we call 'death'. The comedian Woody Allen described such evasion pointedly and humorously when he said, 'It's not that I'm afraid of death. It's just that I don't want to be there when it happens.' Disembodied states in relation to the terror of death will be illustrated in Chapter 11, 'Falling'. One function of the autism of autistic children seems to be to feign 'death' (loss of being), by the reactions of immobilizing their bodies and numbing the sensations in their extremities. By these means, they feel that they avoid sudden and catastrophic 'death' (bodily separateness from the eternal 'breast'), which happens uncontrollably and unexpectedly. In some ways, it is akin to the 'freezing' 0f.a frightened animal. Chiara Cattelan, an Italian paediatrician who, from time to time, brings clinical material from an autistic child for supervision with me, has described her child patient thus: 'M seems like a mummified body. He is like a Pharaoh who finds in death the possibility of keeping his body splendidly intact. His eyes are the only part of the mummy which is not bandaged up,' This image of a mummified body is particularly apt because life in ancient Egypt was dominated by the need to preserve bodily continuity to avoid the ending and parting of death. The penultimate chapter of this book describes a neurotic adult patient whose analysis was dominated by the need to preserve the delusion of bodily continuity, in order to protect her from terrors associated with bodily discontinuity from the mother of her infancy. It was only when, drawing on my work with autistic children, I became aware of her use of crude autistic devices to maintain this delusion, that termination with this patient became a possibility. The next part of the book will be concerned with such neurotic partients.

PART TWO

Psychogenic autism in neurotic patients The sooner the analyst realizes the existence of this hidden part of the patient the less the danger of the analysis becoming an endless and meaningless intellectual dialogue, and the greater the possibilities of the patient achieving a relatively stable equilibrium. Although the analyst has to live through a great deal of anxiety with the patient, I feel ultimately the results make it worthwhile. Sydney Klein, 1980, p,401

CHAPTER ELEVES

Falling He edged forward and looked down. There was a sheer almost unbroken descent on the left and then the cleft in the middle of the cliff, and above that, the tunnel ... He went on hands and knees to the edge and looked down. The cliff was visible for a yard and then turned in and hit itself ... A lump has fallen out of the cliff.

William Golding, Pincher illartin

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his chapter seeks to demonstrate that psychogenic autistic children are in the grip of elemental terrors which are part of the inborn lot of all of us, though not to the same degree. I n particular, it will suggest that the automatic reaction to the threat of falling is one which has immobilized them, and one with which we can empathize. T o d o this, I want to share with you some extracts from an atmospheric paper written by a late friend of mine who, in his first experience of serious rock-climbing, was - in rockclimbing jargon - 'gripped silly' by the terror and fascination of falling. Dave hlunrow was a very normal person. He was a fine athlete, and head of a university department of physical education. T h e paper from which extracts will be quoted (Munrow, 1950) was to be a chapter in a book on the aesthetic aspects of sporting activities. Unfortunately the book was never

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completed, but, before he died, Dave gave me permission to use the paper in any way I thought fit.

I>are's experience of being kripped sill>*' Dave opens his paper by describing the somewhat high-andmighty state of mind in which he, as an inexperienced beginner, started his first climb. Here is his first sentence: 'I remember thinking, this rock-climbing's a piece of cake. There's really nothing to it for anyone with a reasonable sense of balance. I'm a rock monkey. I can soon pick this stuff up.' Dave then goes on to describe the start of the climb in which, in this somewhat inflated state, he climbed nonchalantly and watched the others climbing. But then - as he says: 'there came a flatter moment a period of waiting whilst climber number 3 climbed the pitch below .' T h e experienced climbers had gone on and were out of sight. Jean, who was number 3, was a less experienced member of the group. Dave writes about this waiting time as follows: T h e sun was well down and had been off the rock fall for some time; it was cold in the evening wind. T h e sweat of the afternoon's exertions was now damp and unwelcome. I shivered, chilled by inactivity. 'Bless the girl, I wish she'd hurry up.' But Jean was calling, asking me to let the rope out; she had to retreat from an awkward position and start again. Dave continues : T h e other more experienced climbers were now well away from the crags and just occasionally a faint voice came back on the wind. Otherwise it was quiet; quiet and getting darker and colder. Jean started again and slipped. It was almost nothing - no more than six inches - but the tension in my right leg, as I braced to take the strain, would not go when Jean was climbing again. It was some time later, when I shifted my

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stance to ease the cramp in my leg, that I dislodged a piece of rock - perhaps the size of a cricket ball. I glanced down but found I could no longer do so without dismay ... The very faintness of the stone's final rattles as it joined the scree 400 feet below emphasized the quiet, the height, the space and the isolation ... I was aware only of space and isolation and a vague foreboding, which I could not, even to myself, call fear. When Jean arrived I could only talk in n~onosyllables.I muddled the rope as we changed positions for her to belay: I started to climb again, clumsily and without iest. Dave goes on to describe the rest of the climb, which he did so badly and unskilfully that Alan, the leader, reproved him. During the scramble down, and when they were back at camp, Dave was uncommunicative. He couldn't think about the next day's climbing, but he knew he had to do it. He slept badly. He writes: 'imps of pain played hyde-andseek with lurking doubts amidst the shadows of my mind. I rose neither refreshed nor reassured but dully resigned to see the day through. I felt somehow detached from reality.' He then describes his reactions as they walked to the next day's climb. 'I had a sense of walking away from my problem, of having left it in camp. But,' as he says chillingly, 'it was there waiting for me at the crags.' He continues: 'There within the compass of one gaze, was the whole climb. I knew from the first moment of gazing that all the misgivings of last night were with me still. I felt rather sick . . . There was chatter, but I could not join in.' Dave then describes how Alan suggested that perhaps some of the party might like to walk rather than climb today. As Dave says, 'This was clearly a moment for retreat with honour.' But Dave knew that he must face his horror and not retreat from it, so he opted to climb. He writes: With the certainty of unwanted yet welcome decision, there returned the early morning feeling of unreality, stronger and sharper. I was involved, yet took no part. This was not me standing there, I became a detached observer of my own

186 AUTISTlC BARRIERS IN NEUROTIC PATIENTS body. There occurred a state of emotional cold storage, no excitement, no nervous clumsiness. And so it was that, when Alan called from the top of the first pitch, I watched myself coolly and steadily start to climb. I was an automaton. Following this facing of the terrifying situation, Dave describes the gradual return of his morale and his confidence. Here it is, as he recorded it: 'Alan said, "Dave, move across to your right. There are some good footholds at the edge, and the rock is quite dry".' Dave responds in the following way: These words came from the outside world. I had no idea how much time had passed or how I climbed. There was, in effect, a return to consciousness, a consciousness which became aware of one whole person, all of him - body and mind - striving to climb well and climbing with enjoyment. T h e enjoyment swelled to a confident and vibrant elation. In a moving and vivid way, Dave describes his return to normality. This needs to be quoted at length. Alan was in view for nearly the whole of the first pitch of the buttress, which we climbed with a steady, unhurried ease. As he moved from one stance to the next there was a harmony and melodic quality in his pauses and progress without discord or jarring note. T h e pleasure of arrival at a good new stance in a climb has in it something of the pleasure of striking a new note which rings true, and in tune with others. Having played out his tune, Alan called, and I followed his theme with my own inevitable variations. I reached him and paused, waiting for him to shift so that I could belay and he move on again. But he glanced up the climb, then looked at me, and grinned, 'You lead through,' he said, 'I'll follow.' Surely, the tune which followed, the first I had ever composed myself, faltered and wavered. 1 have only a vague memory of it, but the sense of playing it is clear, etched and enshrined.. . We climbed all day.

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Whenever we rested, hills and sky seemed near and in sharp focus, their beauty almost painful. When we moved, nerve and muscle resonated to each other and execution followed wish with ease and clarity. One played one's perfect part in a vast orchestral pattern. Dave goes on to say that through this experience he acquired a new humility, and that this hypersensitized, intensely personal experience had enriched his participation in common human experiences. Here is how he describes it: As we dropped into the valley with its farms and warm evening lights, so our spirits settled to the tolerable level of conversation and laughter. And back in camp we said we'd had a good day and listened to the stories of the other groups, whilst I smoked a pipe and browsed in the rich contentment of my own secrets.

Discussion Parallels between Dave's experiences and those of autistic patients Much of what Dave says about being 'gripped silly' has many features in common with what we observe, or come to realize, about autistic patients. When patients are paralysed by the autism, they cannot tell us what it is like. It is only as they are emerging from such states that, if we are receptive, they can reveal to us something of its nature. Even this is a matter of hindsight, but we get useful indications about it. Let me remind you of some of Dave's comparable reactions. For example: 'I was aware only of space and isolation and a vague foreboding, which I could not, even to myself, call fear.' This could be an emergent autistic child telling us what the autism had been like. All such patients talk of the terror they felt in that state. For example, Piggott (1979) describes a grown man of twenty-five who had been diagnosed by Leo Kanner at the age of four as s,uffering from early infantile autism, and who had emerged from his autistic state sufficiently to be able to seek

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help from a psychiatrist for the severe troubles that remained. When asked by this psychiatrist what he remembered about being autistic, he replied 'the terror'. The psychiatrist was surprised because, as he said, autistic children do not look terrified. This is quite true. The terror has been kept at bay by their autistic practices. It is only as they emerge from autism that they can tell us about it. Like the autistic child, Dave was wellnigh struck dumb by 'vague forebodings' which flooded over him and made him stand frozen and paralysed on the crags. He says that he could only talk in monosyllables. 'There was chatter but I could not join in.' On the first day, when the horrifying experience had gripped him, it had arrived unexpectedly. It was an unthought reaction to an unconceptualized danger. The sense of danger and the reaction to it were one. It was an automatic reaction over which Dave had no control. In such a situation there is the reaction to shrink away from the drop which looms ahead, and also the need to clutch something solid. On the first day, Dave was virtually struck numb and dumb by the elemental fright he experienced. The next day, Dave's reactions were different. He could begin to marshal his reactions to cope with it. He feared that the horrifying situation would return. As with the autistic children, the reaction is to get rid of it. In their bodily mode of operation, autistic children react by feeling that they sneeze, spit or evacuate the upsetting experience away. Dave expresses something similar, in that he feels that he has left it behind him in the camp. It is an escape reaction. But it does not work for long, for Dave says starkly, in a way which sends shivers down the spine, 'it was there waiting for me at the crags.' He now escapes from it in another way. In colloquial terms, he 'jumps out of his skin with fright'. He says, 'This was not me standing there. I became a detached observer of my own body.' He watches himself climbing like an 'automaton'. 'I watched myself coolly and steadily start to climb.' Tennyson describes such a mindless, disembodied state in

connection with the mourning he experienced on the untimely death of his friend Hallam. He wrote: I leave this mortal ark behind, A weight of nerves without a mind, And leave the cliffs, and haste away

In Memoriam, XII

Dave describes a state of what he calls 'emotional cold storage'. This was a different state from that of the previous day when the 'fright' had descended upon him unawares. He was reacting in a way that would enable him to go on living. He watched himself from the outside with crystal-clear clarity. A friend of mine who was threatened by a fierce dog, in a situation in which no help was forthcoming, described a similar situation of thinking with unusual clarity about what she had to do to get to safety. At certain stages in their treatment, when they are reexperiencing fundamental threats to their 'going-on-being' - of which falling is one - autistic children go through 'out-of-thebody' states in which they behave like a robot or a zombie going through automatic motions. In these states they will say such things as 'He will do this', or 'He will do that9,and not 'I will do this or that.' In a paper as yet to be published, Mrs Enid Balint has described a patient who, for a very long time, only spoke of himself in this disembodied way. Such patients feel that, having left their body, there is an armoured carcass which walks around automatically, and is hollow and empty, like the Tin Man in The U.'izard of Oz, or the hollow men in T.S. Eliot's poem of that name. But Dave's 'out-of-the-body' experiences were of short duration. He writes: 'There was, in effect, a return to consciousness, a consciousness which became aware of one whole person, all of him - body and mind This state of enlarged perception was associated with what Dave calls 'a vibrant elation'. Of this state he writes: 'Whenever we rested, ...I

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hills and sky seemed near and in sharp focus, their beauty almost painful.' His aesthetic vision had been released from numbing terror. When they get out and about again, people who have been confined to hed for a long time through physical illness often describe such intense responses to the beauty of the outside world. As they are released from their autistic capsule, some neurotic adult patients describe aesthetic experiences similar to those of Dave. Anne Bronte expressed this state poignantly for us when she wrote in 'On Becoming': Oh dreadful is the check - intense the agony When the ear begins to hear, and the eye begins to see; When the pulse begins to throb, the brain to think again; The soul to feel the flesh, the flesh to feel the chain. Anne Bronte describes something like the experience of 'hotaches' when a limb is recovering from being frozen. It is the state of some autistic patients as they emerge from the state of 'emotional cold storage'. It was the state of Elly in Chapter 6, who could not talk about the beauty of the moon because of the painful response it evoked. When one contrary becomes fused with its opposite, it is a state of luscious pain, just as when one is facing the edge of a precipice, and the dread of 'falling' becomes fused with the fascination in doing so. Anne Bronte describes this state of fusion of opposites: the return of feeling is an agonizing pleasure, it is an excruciating rapture. T h e study of psychogenic autism is the study of the narrowing of perception through terror, but it is also the study of the undifferentiated fusing of sensation, which gives the state its unbearable poignancy. T h e autistic patient had felt that the only thing to do was to mute this unbearable undifferentiated responsiveness. Some poets seem to have gone through such vibrant but harrowing experiences to emerge to a sharper enriched perception, which, when they tell us about it, makes life more vivid for the rest of us. They have needed great courage to do this; as do the psychogenic autistic children, and

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the neurotic patients with a hidden capsule of autism. As they face their terrors, the autistic scales fall from their eyes; their perceptions become sharper and clearer. T h e psychotherapist helps them to bear this enlarged perception. These aesthetic experiences enrich and enlarge their enjoyment of the ordinary world and ordinary people. Dave implies this when he writes: As we dropped into the valley with its farms and warm evening lights, so our spirits settled to the tolerable level of conversation and laughter. And back in camp we said we'd had a good day and listened to the stories of the other groups, whilst I smoked a pipe and browsed in the rich contentment of my own secrets. But to reach this state, as in the Sagas, the individual has to go through testing ordeals which need to be faced with heroic courage. T h e patient who remains 'gripped silly' by terrors has avoided them by the autistic manoeuvres discussed in previous chapters. T h e psychotherapist's job is to help such patients to face their terrors which, unlike Dave's actual experiences, are illusory ones. In doing this, both therapist and patient come to realize that they are part of a process which is larger than themselves. As the men in the Sagas used to say, 'Men die, cattle die, you die, but the world story does not die.' Dave felt that he became part of a 'vast orchestral pattern', in which he played his part not in a slavish imitation of Alan, the experienced leader, but - important point - with his 'own inevitable variations'. Facing his terrors had enabled him to be enriched by them. It is a state which we hope some psychogenic autistic children, and some neurotic patients with a capsule of autism, can achieve. But this is not an easy task, either for patient or for therapist. Psychotherapy which is closely in touch with the nature of their disorder is essential. It seems to me to be appropriate that poets and artists have been enlisted to help us in this journey into the mind of a psychogenic autistic child, for some of these children (though not all) are poetic, artistic or

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musical. For example, an Italian psychotherapist described an emergent psychogenic autistic child as 'speaking in poetry'. Thus, in the process of bringing them 'down to earth', it is important not to destroy their aesthetic capacities, as some methods of treatment seem to do. On the other hand, we must be realistic about the state of psychogenic autistic children if left in their autistic state. Some workers have idealized these children, to the point of equating them with Contemplatives and even Buddhas. Others have seen them as being engrossed in a world of wonderful fantasy. Neither of these ideas fits the facts. In fact, autistic children are so mentally retarded that they have not developed fantasies or thoughts. They are so undifferentiated from the outside world that they are incapable of imagination and empathic identification with other people (Frith, 1985; Hobson, 1986). Their capacity for symbolization is rudimentary. Theirs is a world based almost entirely on their own bodily sensations, through which they experience a very different world from that which we apprehend by our more developed perceptions. It is very arid as compared with the richness of the world of the normally developing child who can play and use 'let's pretend', neither of these resources being available to the autistic child at the beginning of treatment. However, as we become more closely in touch with such children, we begin to feel an affinity with them. We begin to realize that they are reacting in terms of inbuilt predispositions which are the basis for all human activities. It is for this reason that Dave's account of a state which has parallels with that of a psychogenic autistic child has been presented. But there is another reason for presenting Dave's experiences: in psychogenic autism, automatic reactions to upsetting experiences which seem to carry the threat of being dropped or of falling are very significant. Let me now discuss such experiences. Psychogenic autism as a state of being bnpped silly' As we have seen, Dave's behaviour on the crags has some striking

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parallels with autistic behaviour. He was in the grip of an automatic reaction which had caused his normal functioning to be temporarily suspended. The autistic patient is in a similar state, but there are significant differences. For one thing, it is a much more long-term state. For another, unlike Dave's behaviour, which was activated by an actual situation of unconceptualized danger, that of the patient in an autistic state is a reaction to illusory, though similarly unconceptualized danger. Also, the state of autism arises from a more complicated, interwoven set of factors than did Dave's temporary paralysis on the crags. Inborn patterns associated with falling turn in on themselves, and become intertwined with others which intensify the paralysis, and make emergence from it difficult. Let me now outline some of the elemental psychic factors which give rise to psychogenic autism.

Failure of attachment We are now realizing the importance of the newborn infant's innate disposition to become emotionally attached to the mother, and the serious consequences which are set in train if this does not occur. As we have seen in other chapters, in autistic children this innate disposition has been thwarted by unbuffered awareness of bodily separateness. Unbuffered awareness of bodily separateness As infants, such patients have become aware of bodily separateness from the mother in an immature state of psychic organization, and in a family situation which could not help them with it. This means that they feel unheld, unsupported and unprotected. Such patients seem to have the constant illusion that they are on the brink of being dropped - of falling. This is another important factor in their autism. Threat of falling In psychotherapy, as patients emerge from autism, they show very clearly that they feel on the brink of 'falling' or of being 'dropped'. For example, breaks in the continuity of the physical presence of the analyst, such as

194 AUTISTIC BARRIERS IN NEUROTIC PATIENTS weekends and vacations, are not experienced by such patients as a rejection, as they would be by patients in a neurotic state of response, but as actual physical breaks in a substratum which they have experienced as supporting them. Quite literally and physically, they feel 'let down'. The ground seems to have opened beneath their feet, and they feel on the edge of a chasm which opens before them. In these states, they draw or talk about such things as 'bottomless pits', 'black holes', 'chasms' and 'precipices'. Their early experience of bodily separateness from the mother is being repeated through the medium of the infantile transference to the therapist. This experience has been unthinkable, partly because it was encountered in an immature psychic state, but also because at the time they had no one 'to talk them through it'. Feeling unheld and unsupported, they were caught in the grip of the illusion that they could fall with nothing to break their fall, and with nothing to hold on to. In this state, the patients often talk about having feelings of vertigo. It might be thought that these patients' references to phenomena such as black holes and bottomless pits were metaphors to enable them to talk about preverbal experiences. Autistic children are not capable of such symbolic activities. The original experience had been such as we describe when we say we have a sinking feeling in the pit of the stomach. In their elemental state of psychic development, they had felt that they were falling in to (and had) a void with nothing to catch them or to break a fall. Of course, the original experience, which was preverbal, is distorted by the use of words, but it is the nearest that both patient and therapist can come to it. In a metaphorical way, on a more sophisticated level of functioning, all of us go through the experience of the Fall from the pleasures of the Garden of Eden, into the disillusionment of the reality which is our common human lot. But I have the impression that people who are prone to autistic states were sensitive infants to rear. They seem to be more prone than a less sensuous type of infant would have been to the 'primal sulk'

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described so well by William Blake in the poem quoted at the head of Chapter 1. In their preternaturally hypersensitized state in which, because of their lack of experience of the outside world, illusion holds sway, any minor mishap is exaggerated into a catastrophe. They react to this in a similarly extreme way. The almost complete retraction of 'feelers' is one of these extreme reactions. Being cut off from experience of the outside world perpetuates their hothouse hypersensitivity. The trouble with psychogenic autism is that once it is started, it is selfperpetuating. Psychotherapeutic intervention has to be firm, appropriate and decisive. As we saw from John's clinical material, the tantrum with which he unburdened himself was felt to leave him with a part missing: this was the wonderful, vital 'button'. In his relatively undifferentiated state, John experienced this as becoming detached from his mother's body, as well as from his own. Popular colloquialisms catch up the essence of elemental human states. For example, people often say of such children, 'He is not all there9, 'He has a screw loose.' Neurotic patients with a capsule of autism feel that they are defective in some way. One adult patient referred to herself as 'damaged goods'. John made clear that the seeming catastrophe of losing the 'button' was the pebble which had provoked the landslide into autism. It seems to me to be not insignificant that Dave's traumatized state was intensified by his dislodging a piece of rock, and hearing it rattle on to the scree below. In an unconceptualized way it probably evoked the feeling that he could fall and be 'gone', in just the same way as that insignificant piece of rock, Similarly, in the quotation at the head of this chapter, Pincher Martin gulps with horror when he realizes that a lump has fallen out of the cliff. The feeling of being alone in a precariously balanced situation with nothing to hold on to is intensified if something actually falls. As they begin to speak, autistic children talk of 'wobbly feelings' and of 'whirly feelings'. In such a precariously balanced state, to seem to lose a vital bodily part, which is also a vital part of the

196 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S mother's body, is devastating. The autistic situation of illusion is much more excruciating than Dave's reaction to an actual situation, although that had an element of illusion in it also. One of the reactions to the threat of falling is to try to grasp something. It is very terrifying if it seems to break away from the individual's grasp, and a piece falling can seem to be just that. The disposition to cling on to something in such a precarious situation is seen in patients in autistic states. In describing neurotic patients with a capsule of autism, Sydney Klein (1980, p. 395) writes that autism manifests itself 'by a rather desperate and tenacious clinging to the analyst as the sole source of life, accompanied by an underlying pervasive feeling of mistrust.' This will be illustrated by the patients who are described in the chapters which follow.

CHAPTER TWELVE

Spilling and dissolving I am not yet born; 0 fill me With strength ... against all those Who would dissipate my entirety, would Blow me like thistledown hither and Thither or thither and hither Like water held in the Hands will spill me.

Let them not make a stone and let them not spill me. Otherwise kill me. Louise MacNeice, 'Prayer Before Birth'

T

his is a revised version of a paper prepared for presentation, under the title of 'The dread of dissolution', at a conference arranged by the California Institute of the Arts in March 1985. I t sought to study the fears of spilling away and dissolving experienced by autistic children, and by neurotic patients who have a capsule of autism. Insight into these fears increases our capacity to empathize with these seemingly inaccessible patients in such a way that their sense of identity becomes established and they feel more intact and coordinated. First of all, clinical material from an articulate neurotic patient will be presented. This young woman was the first patient to focus my attention upon these terrors about spilling away - terrors which are deeply buried and difficult of access. In the next chapter this patient's clinical material will be quoted in more detail. Here I shall summarize those aspects of it which

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are relevant to the present theme. The patient will be called Jean. Jean Jean came to see me as a thirteen-year-old girl and as such a severe case of anorexia nervosa that it was feared that she would die. She responded well to intensive psychoanalytic treatment but it was terminated earlier than I thought advisable when, at fifteen years of age, she went to boarding school. She returned to me aged twenty-one, of her own volition and paying her own fees, because she had fits of depression. The summarized material is taken from a sesqion of this second period of Jean's analysis, when the Pandora's Box of her autistic enclave was opened and she revealed to me the terrors which had been shut away there. These revelations came after there had been an unduly extended Christmas holiday due to heavy snowfalls. She came back from this over-long holiday telling me how 'empty' she felt. She went or; to say that she often felt that we were two jugs pouring water into each other, and falling out of control into a bottomless abyss, into spilled out and left her 'empty'. She went on to say that 'deep down, hidden away', she felt as if she were 'a waterfall falling and fal-ling out of control into a bottomless abyss, into boundless space, into nothingness'. She explained to me that it was the feeling of being out of control as much as the falling which was so frightening. Significantly, she said 'I'm afraid I shall lose myself.' She added, 'I know it's an illusion but the terror is real.' It seemed very meaningful to Jean when I reminded her of the time when she had been suffering from anorexia nervosa and she had told me how relieved she had been when her periods had stopped because she had been afraid of bleeding to death. I suggested that the 'waterfall' fear was even worse. If she bled to death, at least she would leave her body behind. But if she were a waterfall which spilled into bottomless nothingness, nothing would be left; she would be a 'no-body, a non-entity'.

199 This understanding led her to showing me that, in these states, 'spilling' was equated with 'forgetting'. In long absences from me (as the mother of her infancy), she felt that I was spilled out of her and she was spilled out of me. Memory traces had been dissolved and she feared that we no longer existcd. After this session with Jean, I was introduced to a paper by Michael Whan called 'Lethe, time and forgetting' (1980). In this Whan says that in Greek mythology Lethe, as well as being the 'Spring of Forgetfulness' in the Underworld, was also 'a condition of the soul which was likened to a leaky pitcher', and that this 'leaking' was associated with forgetting. I was struck by the relevance of this to Jean's material. Forgetting is felt to be lethal. From babyhood Jean had had an unduly close association with her mother, partly because she was her mother's last child, and partly because her father was often abroad due to his work. For Jean, her mother had not become sufficiently differentiated as a person who could seem to catch the torrential overflows of feelings about bodily separateness and absence. T h e fact that her mother died when she was eight years old added to Jean's feeling that there was no alert and alive person to catch the overflows of her powerful feelings about identity and separateness. All this explains why Jean felt that the waterfall of her anguished and panic-stricken feelings about the long absence from me seemed to spill into a 'bottomless abyss', into 'nothingness', and she with them. Since we were not clearly differentiated as separate persons, I was also spilled and 'gone'. Jean felt that vital substances, both hers and mine, had liquefied and been spilled away. T h e word 'dissolution' has in it the notion of change from a solid to a liquid state like, as it were, glass changing into water. In discussing such wordless elemental states it is important to find tltose words which evoke images which are as close as possible to the actual experiences. T h e word 'dissolution' seems to do this. For example, one autistic child feared that he could disappear like some sugar he saw dissolving in water. In the last verse of the poem 'Prayer SPILLING AND DISSOLVING

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Before Birth', quoted at the head of this chapter, Louis MacNeice described such fears of dissolving away and being 'gone'. I n his poem 'Wodwo', T e d Hughes (1970) also evokes for us the feelings of bewilderment and amorphous lack of individual identity associated with such rootless states.* T h e whole poem needs to be quoted to get the atmospheric sense of watery bewilderment which it conveys. 'Wodwo' would seem to be a nonsense word. T h e therapist finds the sense in nonsense (Milner, 1956). What am I ? Nosing here, turning leaves over Following a faint stain on the air to the river's edge I enter water. What am I to split The glassy grain of water looking upward I see the bed Of the river above me upside down very clear What am I doing here in mid-air? Why do I find this frog so interesting as I inspect its most secret interior and make it my own? Do these weeds know me and name me to each other have they seen me before, do I fit in their world? I seem separate from the ground and not rooted but dropped out of nothing casually I've no threads fastening me to anything I can go anywhere I seem to have been given the freedom of this place what am I then? And picking bits of bark off this rotten stump gives me no pleasure and it's no use so why do I do it me and doing that have coincided very queerly But what shall I be called am I the first have I an owner what shape am I what shape am I am I huge if I go to the end on this way past these trees and past these trees till I get tired that's touching one wall of me for the moment if I sit still how everything stops to watch me I suppose I am the exact centre but there's all this what is it roots roots roots roots and here's the water again very queer but I'll go on looking. *I would like to thank Jeanne hlpgilana for iiltroducing me to this poem.

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Hughes' poem expresses very cogently the bewilderment associated with states in which the sense of personal identity is under threat and things are perceived as utterly discrete and separate because there are no threads linking them together. Connections have broken down or have not been established. The threat of watery dissolution is in the air. Everything has to be inspected carefully, and the works examined. Nothing can be taken on trust. There is a vacuous sense of lack of purpose, of understanding, of meaning. There is no coherent picture of the world nor of the subject himself. He lives in a peripheral world of vague guesses, conjectures and speculations which have no basis in previous experience. There is a sort of prehensile awareness. Like the monkey using his tail to swing from branch to branch he apprehends one thing after another but does not comprehend them. Indeed, spilling away can be equated with loss of comprehension. This comes from lack of the sense of being encircled by caring understanding and meaning. There are no boundaries. It is a state of unfocused undifferentiation. In part, Hughes makes this point by the lack of punctuation in his poem. For the autistic child who lacks this encirclement, the autistic encapsulation has been a protection against the threat of dissolving away. Every change of state or circumstance means the recasting of previous formulations of experience. In his rigid state of keeping dissolution at bay, this is a dangerous threat to the psychogenic autistic child. Changes mean that everything is thrown into the melting-pot; he is in a state of flux which has to be borne if trans-formations are to occur. This state of flux can only be tolerated if the child has experienced lively reciprocal trans-actions with an adaptable nurturing person. Without these, he lives in an 'all or nothing' state. Formulations are either 'there' in their entirety, or they are 'gone'. The midway state of suspense in which they are gradually transformed cannot be tolerated, because if rigid formulations are threatened with change they seem hopelessly shattered. The child no longer feels invulnerable. Vital substances threaten to spill away.

202 AUTISTIC BARRIERS IN NEUROTIC PATIENTS After there had been a change of therapy room, for example, a little girl being treated by Verena Crick said, 'I'm afraid I'm losing my characteristics.' Her characteristics seemed to threaten to spill out of her to be lost. She was 'forgetting' who she was. She feared that she could dissolve away and be gone. Of course, Ted Hughes was not overthrown and submerged by this situation of flux, as is the autistic child. He was sufficiently secure in his own identity to be able tp empathize with such states of non-identity, and then to re-experience his own identity with a strengthened capacity for compassion. He seemed to be experiencing our ignorance about the ultimate nature of things, alongside echoes of the earlier bewilderment felt by the' small child who is surrounded by a sea of meaning which, by its meaninglessness for him, has threatened to overwhelm him. Like Louis MacNeice in 'Prayer Before Birth', patients such as Jean prefer death to the feeling of being dissipated and spilled away. In despair, Jean felt that death through starvation was preferable to the unco~trollabledissolution which threatened her. At least she would be in control, and her struggle to defend her 'entirety' would be at an end. Louis MacNeice had managed to enclose his waterfall feelings within the disciplined context of a poem. Jean was also stimulated to keep her torrent of feelings within the context of amateur dramatics and music, in both of which activities she had considerable talent. But immense and powerful feelings were always surging out of the confines of these creative activities, bringing the terror of spilling away and being 'gone'. The reaction to this threat was to 'seize up' and to stop doing anything. Jean's enjoyment of life and of her undoubted capacities was continually being halted by this fear of spilling away and losing herself. It was this depression which had brought her back to me.

Sylvia Plath Jean's fears have much in common with those of Sylvia Plath, who was the first wife of Ted Hughes. Focusing on the function

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of the skin in early psychological development, D r Biven, a psychoanalyst from Ann Arbor, Michigan, has studied the poems and writings of Sylvia Plath, as well as Alvarez's biography of her, in order to get in touch with her struggles to preserve her 'entirety' against the floods of feelings which threatened to submerge her (Alvarez, Al, 1963; Biven, 1982). As with Jean, it seems likely that Sylvia Plath, as an infant and small child, had been unduly merged with her mother, and then experienced her bodily separateness before she had sufficientky emerged to a state in which she could cope with feelings about individual identity and separateness. For example, Plath writes as follows about her feelings when she learned at the age of two and a half that her mother would soon be home with a new baby :

I hated babies. I, who for two-and-a-half years had been the centre of a tender universe, felt the axis wrench and polar chill immobilize my bones .. Hugging my grudge, ugly and prickly, and sad sea-urchin, I trudged off on my own, in the opposite direction towards the forbidding prison. As from a star I saw, coldly and soberly, the separateness of everything. I felt the wall of my skin; I am I. That stone is a stone. My beautiful fusion with the things of the world was over. (quoted in Biven, 1982)

.

Obviously, Sylvia and her mother had been in an undue state of fusion with each other, so that the birth of a new baby was a terrible shock. In such a situation of fusion the child would seem to use the mother as an autistic object or as an autistic shape - that is, the mother is experienced as a sensation part of the child's body. When sudden awareness of bodily separateness is forced upon the child, he or she feels wrenched apart from the mother. Without having had sufficient preparation for this, such.a child is plunged into intense emotional states about bodily separateness. Sylvia Plath experienced that stark icy coldness and loneliness which patients with a capsule

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of autism often describe to us, and which Graham Greene has described, in A Sort of Life, as being characteristic of some writers. 'There is a splinter of ice in the heart of a writer.' T h e icy clarity of 'I am I' as expressed by Plath seems to indicate that her sense of identity is precarious and tenuous. After struggling for years to cope with her fears of dissolution, Sylvia Plath finally took her own life- possibly, in part, to get away from this threat. In the passage which was quoted above, Sylvia Plath might have been writing about the onset of autism. But because she experienced the pain of the 'axis wrench' and the 'polar chill' at a later time of life than do autistic children, for whom they occur in early infancy, she did not become massively autistic. She was able to catch the torrential overflows of her undigested, passionate feelings within the context of her poems. However, throughout her life she obviously experienced the autistic backward 'drag' to her ongoing development which one of my patients has described as the 'undertow'. Biven tells us that Sylvia Plath felt her skin to be an artificial barrier that had to be 'penetrated', 'peeled away' or 'melted'. Autistic children feel like this also. When they experienced the 'axis wrench' and 'polar chill' they reacted by callusing themselves with hard autistic objects, or by wrapping themselves in softly soothing autistic shapes. These delusions make them feel that they have an artificial, inert barrier rather than a living, breathing human skin. This barrier keeps at bay the 'nameless dread' that they could liquefy and spill away. They have made their own containment. But this rigid encapsulation has prevented them from using the more adaptable containment of human relationships. T h e longer they stay in their rigid, self-enclosed state, the more they remain in the grip of 'nameless dreads'; and the more difficult it is to get in touch with them to help them to develop the sense of having an adaptable physblogical and psychological 'skin'. This, as a permeable membrane, would filter their experience so that

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excesses of stimulation are moderated and transformations can take place (see Anzieu, 1974; Bick, 1968; Freud, 1911). Biven describes a neurotic woman patient who told him that she literally felt that she had no skin sometimes. In this state she described herself as 'being hidden and little, inside a walnut shell' (Biven, 1982). I call autistic children 'shell-type' or 'encapsulated' children. Jean did not open the 'walnut shell' of her autistic enclave until the second phase of her analysis. As well as being afraid that they will 'spill away', their lack of the sense of being anchored to a caring and cared-for nurturing object makes such patients fear that they will float away and be 'gone'. This increases their desperate autistic manoeuvring to maintain the illusion of controlling their surges of passion by self-enclosure. Let us now follow the odyssey of a five-year-old autistic boy, Steve, on the 'wine-dark sea' of personal development in the ship of psychoanalysis. You will remember that on his arduous journey back to his home base of Ithaca, as Odysseus was often buffeted by storms and waves. Homer describes how as Odysseus lay exhausted on some forlorn island shore, his limbs were 'loosened', and his body 'ran like water'. He was threatened with dissolution and extinction. Steve's journey away from the threat of impending dissolution to the security of caring connections within the context of a human family, in which he could learn to manage his tempestuous feelings, was presented for my supervision in Paris by a talented psychotherapist called Madame Cauquil. (We met Steve and Madame Cauquil briefly in Chapter 8.) The significance of her name, having a clang similarity to la coquille (a shell), played its part in the psychotherapy. Stee~e Steve was referred to Madame Cauquil at five and a half for 'repetitive convulsive episodes without any precise medical explanation'. The convulsions started at six months, when his

206 AIJTISTIC BARRIERS IN NEUROTIC PXTIENTS first tooth appeared. ( D r Guilianna de Astis and Professor Giannotti (1985) have found that the advent of dentition precipitated the first signs of autism in some of the autistic children seen by them in the Psychotherapy Unit of Rome University's Institute of Childhood Neuropsychiatry.) Steve was not toilet-trained until he was four years old, because until then he had been afraid of being put on his potty. His mother described him in this situation as appearing 'terrorized as if he might fall.' At three years of age Steve began to fall in actual fact, 'contracting his foot and toe without any organic cause'. At four, as he became toilet-trained, Steve began to utter a few words - 'Mummy', 'Daddy', 'car' - but he never used the personal pronouns 'I' or 'you'. When he was first seen at the clinic, Steve ate only with his hands and drank ten to twenty bottles of fluid a day. He had stereotyped gestures, he rocked, he bit his hands and hit his forehead on the floor. He handled objects without really playing with them. ( I n my terms, they would be autistic objects.) T h e clinic team thought the mother seemed 'depressive, fragile and rather undifferentiated from her son'. T h e father would not be involved in the treatment, but he did not oppose it.

The course of treatment

It would make this chapter too long if I gave you the detailed account which Madame Cauquil presented to me; I can pick out only the significant features. In his first session Steve demonstrated one of the means by which he dealt with being separated from his mother. After his mother left the consulting-room, he turned his back on Madame Cauquil, and with his spit made so many whorls and scribbles on the window-pane that it became impossible to see through it. Madame Cauquil felt him to be completely inaccessible because, in her words, 'He seemed to be wrapped in a wet universe which he himself secreted.' Steve had distracted his attention away from his mother's departure by resorting to idiosyncratic, unshared shapes made from his own body sub-

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stances. In this state of oblivion he was cut off from human sympathy and human care. Madame Cauquil also sensed that Steve felt 'glued' to the window by his spit. It is possible that in his panic at the disappearance of his mother, Steve clung to something solid in order to feel that he was 'there' and not 'gone'. His spit was like the trail made by a snail. After one-and-a-half years of therapy, Steve drew a red oval containing two shapes, a smaller oval and a circle. Madame Cauquil felt (and I agree with her) that the two containers within a larger container indicated that Steve felt that he and his therapist were held within a shared ambience. He was beginning to realize that there could be bodily separateness between two people who were held together within a context of 'togetherness' of a non-physical kind. Within this context of mental 'togetherness' Steve could begin to 'think', for as he drew the containers he said, 'It made a lot of noise when ... thought Cauquil.' He probably left out the personal pronoun 'I' because his sense of personal identity, as also his capacity to think, was dependent upon his 'togetherness' with Madame Cauquil. In Kleinian terms this was an instance of projective identification, which Bion has demonstrated as being instrumental to the beginning of thinking (Bion, 1962a). However, Steve's sense of bodily separateness within a context of mental 'togetherness' did not feel secure. Following the 'container' session he said in panic, 'It's leaking ... everywhere .., you ... put ... kaka,' meanwhile defecating into his pants. From then on 'the wet', as Steve called it, became very important for him. In Madame Cauquil's words, 'It is as if we both share the same liquid bath which offsets the worry about physical discontinuity.' However, this encirclement by the communal flow of non-verbal communion was disturbed by the threat of the summer holiday. Steve was not able to feel that their bodily separateness from each other could be bridged by his, as yet, insecure capacity to reflect, to think, to remember, to communicate. In terror, he reverted to the delusion of

208 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S undifferentiated bodily fusion with the mother in order to avoid the threat of dissolution, which came as soon as he was assailed by the realization of his lack of bodily continuity with her. In his poem 'Flash-back' James Greene, (1980, p.9) expressed these terror-struck states of separation very vividly. He writes : If I cannot suck My thumbs, If like lightning I all-but crack A minus, non-plussed Will you hold me - criss-cross - in your arms, A gentle straitjacket? . . . Oh fuse me with the surplus of the thunder Whose brain is racked And under fire . . . T h e words 'all-but' and ' - criss-cross - in your arms' are hyphenated as if to suggest the reactive states of fusion caused by panic about bodily separateness. In Steve's developmental history it was reported that, in his convulsive episodes as an infant, he could only be calmed by being held in his father's arms. As infants, autistic children do not suck their fingers or thumbs, but resort to autistic objects and autistic shapes for the relief of tension. These self-generated protections and comforts distract their attention away from the terror of 'spilling' or 'leaking' away and of disappearing altogether. In using the phrase 'A minus, non-plussed' Greene. expressed the arithmetical exactitude of these children, and their Sartrean horror of becoming a 'nothingness' (Sartre, 1957). Greene's mention of a 'straitjacket' implies that the unthinkable, uncontrollable overspill which seems to threaten dissolution is what we call 'madness'. Autism is a defence against this madness. T h e autistic self-generated practices make rigid 'straitjackets' to prevent dissolution. T h e therapist becomes the child's 'gentle straitjacket' replacing the autistic object which is mcrcilesely constricting. On the day that Madame Cauquil told Steve about the dates of the coming summer holiday, Steve

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kneaded the plasticine, actively masticated it, and then mumbled several words as if they were jumbled and stuck together: 'Girlie - Cauquil- eaten - bitten - all-meat - broken - it's leaking.' Madame Cauquil was quick to understand his jumbled outpourings well enough, for she said to him, 'When we are going to be separated for several weeks you feel you want to stick to me and have 'girlie-Cauquil' all to yourself. You are so unhappy about not being able to do this, and soaangryabout our separateness that you are afraid that you have bitten and broken me, and that I will leak out of you and be gone.' Following this interpretation Steve took the pieces of plasticine out of his mouth and, showing Madame Cauquil a broken, sausage-like thing made from the plasticine, said 'Glue-hole'. When she offered him Scotch tape, he said 'Cut', and taped the plasticine by himself, 'to reconstitute the long sausage-like thing, winding the tape specially round the broken part'. On his return from the summer holiday, Steve carried his work concerning the long sausage-like thing still further. The father element now came into the picture of his world that Steve was creating with the help of his therapist. Until the disciplining father element becomes an active presence, the threat of dissolution remains. The father brings into focus the reality that sharing is an inevitable part of life. It now became clear that Steve felt that the father had come between him and 'girlie-Cauquil' during the holiday. Angrily pushing a red toy car out of the way, Steve said 'Red car broken'. This is reminiscent of John in Chapter 4 who, in similar circumstances, said 'Red button broken'. Steve was now confronted with what I have found to be the critical situation for the ailtistic child. In his concern about the long sausage-like thing, Steve showed us his present-day version of the painful situation which provoked his selfenclosure by the autism. Let me go into this in some detail. In the 'water bath' situation Steve seems to have been reenacting a very early state in which sensations of being in the

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watery medium of the womb linger on to create a kind of postnatal womb. As Freud (1926) reminded us, 'There is much more continuity between intra-uterine life and earliest infancy than the impressive caesura of the act of birth allows us to believe.' This continuity would seem to be a necessary interim period during which the newborn infant makes the adjustment from being a water creature to the frustrations and labours of living on dry land. In the womb-like communal medium of the 'water bath' situation, Steve feels that he and his mother1 therapist flow around and into each other to make a sheltered situation in which they can begin to forge affectionate and sensuous links with each other. He can begin to experience his separateness from her in a situation in which he is encircled by the safety and warmth of her understanding. Shared meanings develop between them. In this situation he can begin to get emotionally 'rooted' in the earthy mother, who acts as what Madame Cauquil called a 'mother sponge', to mop up and give meaning to his bewildering and bewildered overflows. Before he could re-experience this early state, the autistic shell had to be scaled away. This rooting process has something in common with the 'bonding' or 'attachment' described by the ethologists, but there are human features to it. It is inaccurate to extrapolate simplistically from animals to man. This rooting would seem to be a prerequisite for object relations as described by the psychoanalysts. There is nothing mystical about this process. It is mediated through the psychophysical capacities for empathy and imitation which are inherent in the nature of human beings, and which, as observations of babies by non-psychoanalytic observers are showing, begin to develop in the first few days of the infant's life. But for Steve, as for all autistic children, the shelter for this important rooting process was always being disturbed. T h e link with the primordial mother was always being broken. This 'axis wrench', to use Plath's phrase, meant that Steve was constantly threatened with dissolution and extinction.

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Like many autistic children, Steve had had a depressed mother in early infancy. He must often have felt that her empathic, responsive connections with him were absent or sagging. He must have feared that he would slip out of the focus of her attention, and be gone forever. In his panic he clung to inanimate objects and to his mother as an inanimate object. All this was being repeated with Madame Cauquil. With no separateness between them he cannot think or hold her in his memory. Without memory he cannot develop a belief in the continuity of existence, his own and other people's, and that of objects in the outside world. Thus, he can never feel safe. Without such 'basic trust' (Erikson, 1951) the painful impingement of cutting his first teeth must have been a terrifying event. Something was happening to him over which he had no control. It sent him into convulsive fits of panic and rage. His jumbled volcanic explosion of speech in the session before the summer holiday now becomes more understandable. It seems likely that Steve had been reliving, through the medium of the transference, the cutting of his first teeth. In present-day terms he felt that 'girlie-Cauquil' was 'bitten' and 'eaten' like 'meat', and then he felt that she was 'broken' and 'leaking'. He was afaid that she would leak away from him and be 'gone'. In his state of fused undifferentiation from her, he felt that he would leak away also. He felt that his solidity and his 'thereness' were evaporating. He was slipping away and losing his grip on solid and secure reality. In his terror, everything became jumbled together on the basis of rough-and-ready similarities. Thus, I suspect that the long sausage-like thing seems to Steve to be a 'mishmash' of 'red car - red nipple sausage - penis - Daddy -tongue', etc., all of which are felt to be broken. It is similar to John's undifferentiated reactions to the red button, the button on a cushion, car, Daddy, etc. T h e important process of becoming 'rooted' which leads to the capacity to make differentiations, and to become established as a differentiated entity in their own right, has been interrupted and muddled in these patients.

212 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S Steve's uncontrolled and inarticulate outburst of panic and rage about the frustration associated with anything which prevented immediate and ever-ready direct access to the mother disturbed the fundamental relationship he had been establishing with 'girlie-Cauquil'. Fortunately, Madame Cauquil understood this desperate situation of terrified, possessive jealousy well enough to help him with it for, apropos his play with a fireman's truck, she said to Steve, 'Waiting for me to come when I am with others is like a fire in the head.' You will remember that in the poem quoted earlier, James Greene wrote 'Whose brain is racked1And under fire ...' In short, Steve felt possessed by passionate, fiery feelings about the frustrations inherent in human relationships. These have to become regulated if his 'thereness' is to be securely established so that he no longer suffers the threat of dissolution and 'nonbeing' which is not under his control. In an autistic state, if he cannot feel fused with the mother, he would rather feel fused with the thunder, as James Greene expressed it; even if, as in the case of Semele who was destroyed by Zeus, it should lead to extinction. We saw from Jean and from Louis MacNeice that destruction brought about by themselves is preferable to experiencing the uncontrollable, overwhelming terrors about spilling away associated with bodily separateness from the mot her. Steve now showed his therapist how ineffectual his autistic attempts to regulate his passionate feelings had been. At the same time as he drew a body with a torso like a tube marked with a graduated measuring scale, Steve filled a glass tube with his spit which he called 'fuel'. This tube also had a graduated measuring scale to check the level of the fuel. After a while, he -said 'Tube broken'. Steve seemed to be aware that a rigid, inflexible, self-made tube was not strong enough to bear the violent ups and downs of his turbulent emotions, experienced in terms of bodily fluids. He was also realizing that these emotions were imporiant in that they 'fuelled' his activities, and that to do this they must be regulated in an appropriate way.

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After this, Steve moved on to trying to find a more effective way of managing his ungovernable feelings. He began to feel connected to his therapist as if she were a washing machine. This went on for some time until finally, in a session before the Easter separation, Steve drew a pipe on the blackboard such as would connect the washing machine to the tap which supplied the water. T h u s the cleansing 'washing machine Mummy' was connected to the 'Daddy tap'. But in his terrified state of anguished jealousy about the coming separation from his therapist, Steve erased the drawing of the connecting pipe so that the cleansing 'washing machine Mummy' was no longer connected to the 'Daddy tap'. Unconnected to the Daddy tap, the mother's capacity to function in a cleansing way was destroyed. This meant that she could no longer function in this way for Steve. His survival was at risk. Fortunately, Madame Cauquil understood his fears sufficiently to say to him: 'Are you afraid that you are gone, leaked out, forgotten, when you know that we are to be separated for Easter?' (You will notice that she has not harped upon the destruction of the links, but has concentrated upon the fears which led to their destruction.) Steve responded to this by saying, 'And soap smells good.' Following this train of thought, Madame Cauquil replied: 'Yes, that's true. T h e odour lasts and afterwards we can remember it.' Wrapped around by the network of associations, meanings and understandings that he and his therapist were weaving together, Steve no longer needed Madame Cauquil to accompany him down the corridor which led from the consulting-room to the waiting-room. His need to cling to her, as a physica.1 object to protect him from spilling or floating away in either water or air, was being moderated by the establishment of fragrant memories which linked them together in times of absence from each other. The space between them was beginning to be tolerated and connections could be made across this space. In this period Steve drew a cohesive human body with all

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the connecting pieces such as the neck intact and in place. His bodily movements became more co-ordinated, and his speech more coherent. Steve was obviously well on the way to achieving a cohesive sense of self. At which point we will leave him in the capable hands of Madame Cauquil. Like Odysseus, Steve is almost home to Ithaca where the faithful Penelope, who understands the importance of weaving, waits for the solitary traveller to return from his voyage of self-discovery. This chapter has sought to show how seemingly inaccessible patients can be helped to feel less immobilized by fears of spilling and dissolving. Insights about these fears have been culled from work with psychogenic autistic children. Work with such children leads us to think about such ultimate things as 'existence' and 'non-existence'. T h e children themselves are not metaphysical philosophers but, if we are to help them, and if we are to survive their onslaught upon our sanity, we have to work within the framework of a developed philosophy, using a kind of poetic science.

CHAPTER THIRTEEN

The development of 'I-ness' The baby new to earth and sky, What time his tender palm is prest Against the circle of the breast, Has never thought that 'this is I :' But as he grows he gathers much, And learns the use of 'I', and 'me', And finds 'I am not what I see, And other than the things I touch.' So rounds he to a separate mind From whence clear memory may begin As thro' the frame that binds him in His isolation grows defined. Tennyson, In Memonam, X L I ~

n another form this was a paper published in Winnicott

Studies (1985) 1 : 3 6 4 8 . Its starting point was the fact that a definitive characteristic of psychogenic autistic children is the speaking children's non-use of the personal pronoun, and the mute children's obvious lack,of personal identity. T h e paper sought to study the impediments to their sense of being an 'I,, and to illustrate some of the steps whereby this process takes place during the course of psychoanalytic treatment. Illustrative case material from the treatment of psychogenic autistic children was presented to demonstrate the importance of the body image in the process of becoming an '1'.

.Veurotic patients with a capsule of autisnt Certain neurotic patients have much in common with autistic children (Klein, S., 1980; Tustin, 1978). Such patients feel that they are unreal and that 'life is just a dream'. On deep

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investigation it becomes clear that their sense of existing as a person is tenuous. In such patients, cognitive and affective development seems to have taken place by bypassing a 'blind spot' of arrested development which then becomes a capsule of autism in the depths of their personality. In this capsule, as in the overall encapsulation of autistic children, there are all the potentialities for the development of self, but secure and authentic self-representation has never been satisfactorily achieved. These neurotic patients can often put into words the primordial non-verbal states in which the development of a sense of self had been grossly impeded or impaired. Of course, in this verbalization the nature of these non-verbal experiences is somewhat changed. But patients are very motivated to try to find words to express these non-verbal states as evocatively and precisely as possible, and what they tell us (and what the poets can tell us) is probably as close as we can get to a description of such experiences. (The psychosomatic illnesses of such patients are also often an attempt to give overt expression to these body-centred experiences.) Thus, the first clinical example to be used to develop the theme of this paper will be taken from work with a neurotic adult patient. It indicates the fluid nature of the early proprioceptive body image and the part that these sensations play in the establishment of a sense of existence, which is basic to a sense of self. The term 'image' for these early states is, however, somewhat of a misnomer since the child, at this stage, is incapable of 'imaging' in the precise meaning of the word. These early states seem to be a repertoire of relatively uncoordinated sensations which are sensed rather than imaged. And yet the best way for us to communicate about them is by means of evocative imagery. In an interesting television programme on the body image, Dr Jonathan Miller (1981) coined some telling phrases, one of which, the 'felt-self', describes the early situation very well. Of this, he said: 'The felt-self is a private phantom housed in a public body.'

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The neurotic adult patient whose material is about to be presented had to use images from her later, speaking experiences to try to communicate about these primordial, nonverbal, bodily states. The images indicated the fluid nature of her early body experiences. They also expressed the uncontrollable nameless terrors of being 'gone' - of not existing which had been associated with these fluid states. Being nameless and inexpressible, they had seemed to be the unstoppable. The terror of the unstoppable had interfered with the development of a secure and normal body image, and thus of a secure sense of identity.

Clinical example I Jean was discussed in the last chapter, and you will remember that at thirteen she had been severely anorexic but had responded well to psychotherapy. However, at the age of twentyone she had returned to psychotherapy because she had fits of depression. You may also remember that Jean said that she felt that we were two jugs pouring water into each other, but that her jug had a hole in it and water spilled out of it. She also said that she felt as if 'deep down' she were a 'waterfall'; 'falling and falling out of control' into a bottomless abyss, into boundless space, into nothingness. She emphasized that it was the feeling of being out of control, as much as the falling, which was so frightening. Significantly, she added, 'I'm afraid I shall lose myself.' (At this point I was reminded of an old lady whom I used to visit in an old people's home, who always referred to her afternoon nap as 'losing myself'; for example, 'I just lost myself for ten minutes.' When she was in a confused state after being moved into hospital, she said, 'I'm afraid I'm losing the image of myself. ') I responded to Jean by saying that I thought that 'deep down' referred to experiences she had had very early in her life. She seemed to be saying that in the beginning of her life she had felt her body to be composed of fluids which could be spilled so that

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she lost all sense of having a body- of existing. She said that this interpretation had been very meaningful to her. I pointed out to her that the fear that she would lose her existence was even worse than being afraid that she would die from bleeding to death. If she died, at least she would leave her body behind, but if she stopped existing, it would be complete annihilation, nothing would be left. She would be a no-body - a non-entity. After a short pause, she reminded me of a remark she had made in the first phase of her analysis about something which we had both recognized to be an illusion. She had said, 'I know it's an illusion but the terror is real.' 1 replied that I thought this applied to the terror of losing her existence - of becoming a 'nobody'. She knew that it was an illusion but the terror was real. However, realizing that it was an illusion could help to mitigate the terror to some degree. There was silence whilst I felt that we both thought about this; I broke the silence to ask her what she was thinking. She said that she was thinking of the hymn, Time like an ever-rolling stream Bears all its sons away They fly forgotten as a dream Dies at the opening day. Jean came from a religious background, so I said that to think about a hymn was often comforting in states of terror. I went on to say I had noticed, in this session, that we had both kept referring to the previous phase of her analysis, before she went to boarding school. Perhaps the unduly long Christmas holiday had re-evoked the feelings she had had between the ending of that first phase and her return to analysis now. She had told me that during the time when she was at boarding school, and afterwards, she had been afraid that I would forget her and that she would forget me. She was showing me that, in the depths, 'forgetting' was the feeling of everything being spilled out of her and out of me. She experienced this as losing her sense of existence - of feeling 'gone'. After a pause Jean went on to tell me that Alfred, the baby

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she had looked after when she worked as a mother's help to a family in her village, was now four years old. He had had to go into hospital and was very depressed and would not speak to anyone; he would only talk to his teddy bear. She said that she had a similar teddy bear. I suggested that she was telling me that long gaps in being away from me, as the mother to the baby parts of herself, seemed like being in hospital seemed to Alfred. She felt angry and depressed; she was feeling like this now; she didn't want to speak to me and could only talk to her teddy bear. However, I suggested that she had moved on from feeling like a waterfall - a 'thing' - completely out of control, with no boundaries and no solidity. She now felt that she was more of a flesh-and-blood person with solid things to cling to, like a teddy bear. But she wanted to ignore me, just as Alfred ignored everybody. By so doing she felt that she could make me 'gone'. In the baby depths, 'looking' was felt to make me exist, 'not looking' was felt to make me 'gone'. She wanted to make me 'gone' because she felt that there was a fixed amount of the water of existence and only one of us could have it in our jug. She felt that we were in deadly rivalry for this vital thing. If she could stop me from having it, she could have it. I went on to say that these early baby feelings got in the way of co-operating with me as a person from whom she wanted help, and to whom she felt grateful. All the way through this girl's analysis, predatory rivalry (Gaddini, E., 1969) constituted the biggest hazard to the establishment of a secure sense of self. Phantasms formed from these unacknowledged, savage feelings 'dogged' each step of progress as it seemed imminent. However, on this particular day, after the above interpretation, the atmosphere relaxed, as if - for the time being, at any rate - we had sufficiently worked over the intense feelings aroused by the unduly long holiday. Her next association concerned conflicts we had been working on before the holiday. It is significant that after this session there was a marked change in Jean. She began to sleep better. She became more

220 . 4 U T I S T I C BARRIERS IN N E U R O T I C P A T I E N T S self-confident and self-reliant. She developed more initiative: for one thing, she formed a relationship with a very suitable young man. The terror of being at the mercy of her uncontrolled 'waterfall' feelings seemed to have been alleviated to some extent. In a subsequent session, she told me that 'nowadays' she felt as if she 'had something solid to hold on to'. Discussion of Jean's material I felt that in this session we became in touch with a part of Jean's early experience which had been sealed off but had continued to give her trouble. In the depths, she felt fretted with terror and uncertainty. In this state she felt as if she were a flux of sensations which were not bounded or controlled. She had little sense of having a body which contained them. In this state, unrelieved panic and terror were experienced as being turgid with fluids which overflowed in an uncontrollable, waterfall-like fashion. From our adult point of view, the children are tense and impulsedominated. The child's experience is of being massively spilled and overflowing in a rushing, uncontrollable way. It is the essence of madness. With this capsule of madness at the base of her being, Jean's sense of 'I-ness' was very impaired. She had intense feelings of unworth. She felt 'no good', a 'nonentity' - a 'nobody'. In the depths she feared extinction and 'nothingness'. In such a state she felt that she had a 'hole'. Autistic objects - in this case, the inconsequential chatter seemed to plug the hole (see Chapter 6). Later, when she talks about Alfred's reactions to being in hospital, she begins to feel like a flesh-and-blood person who can use a transitional object - the teddy bear - to solace her loneliness and help her to feel held together and attached to something. The development of this transitional area provided an important half-way house between feeling that she was a mass of fluids, which could slip or be taken away from her to make her 'gone', and the sense of having a secure body image and a sense of self which had continuity of existence. The

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possibility of developing relationships with other people is emerging. This half-way 'transitional stage' (Winnicott, 1958) will now be illustrated by clinical material which demonstrates that awareness of solid objects as separate from the body is a necessary prelude to moving on from a predominantly fluid 'felt-self' to 'transitional' states. In such states there are felt to be inner and outer structures which can contain and control the fluids which overflow and become out of control. Lacking such regulating structures, autistic children feel that they can be trodden underfoot like an insect, as in Kafka's story 'Metamorphosis' which clearly described Kafka's own terrors. Kafka's preoccupation with 'the Law' demonstrates the psychotic's need for, but lack of, inner structure. Psychogehic autistic children have tried to compensate for lack of this by the delusion of hard external encapsulation. But they have become entrapped by their autistic devices. Reactions which developed to control the 'overflow' have resulted in damage to their capacity to relate to others. With the establishment of inner regulating and stabilizing structures, tension begins to be sustained, and actions delayed until appropriate means of expression are available. In such a situation, intentionality and purpose begin to be manifested. The child begins to feel that he has something solid and reliable to hold on to and to push against.

Clinical example 2 Clinical material will now be presented to illustrate the beginnings of a movement towards having an inner structure which 'contains' and transforms raw impulses. A session is taken from the therapy of a five-year-old psychogenic autistic boy who is being treated by a French psychoanalyst, Dr Anik Maufras de Chltellier, who discusses her work with me from time to time. On the day in question, when D r Maufras went to fetch Pierre from the waiting-room, she was surprised to find

222 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S that he was building with bricks in the middle of the waitingroom floor, Previously, he had either been flitting around the room in a floating sort of fashion, or sitting quite still beside the person who had accompanied him to the clinic. Also, unlike on other occasions, he now walked purposefully down the corridor to the consulting-room with an upright back as if he had the sensation of having a hard backbone to support him. On previous occasions, he had always flopped down outside the waiting-room door and had had to be supported or half-carried to the consulting-room (see Alvarez,, Anne, 1980). On this day, Pierre also did an unusual thing in the consulting-room. With great intent, he drew something on the paper Dr Maufras had provided for him. He said that it was a volcano. This 'volcano' had a passage-like space down the middle of it through which, he said, the lava erupted. There was also anxiety about some sugar which he saw dissolving in water. Pierre was now able to tell D r Maufras about feelings which had previously been inexpressible. T h e tension of waiting for her to come, and the excitement to get to her room, seemed to him as if his body passages were full of lava-like fluids he could not hold in. In previous sessions this lava had seemed to erupt and to make him feel 'gone', so he flopped to the ground. In this state, his sense of existence (of 'being') was tenuous. He feared that he could dissolve away and be 'gone' like the sugar. Today, he had been able to play with the hard bricks, which had enabled him to wait and to make him feel stronger. He had been able to feel that he had a hard backbone to support him. He had been able to hold the lava-like sensations in check, to wait to represent them on paper so that he could share thern with D r Maufras. He felt held in her attentive awareness so that his overflow could be anticipated and contained. He was less afraid of erupting like a volcano and of becoming 'gone'. He was developing the sense of having a firm body image. Autistic children 'rubber-stamp' the outside world in terms of their body image - their 'felt-self'. In his BBC television

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series in 1981, 'The Human Body', Jonathan Miller expressed the idea that 'the felt image is a fiction - an imaginary space rather like a jelly mould.' T h e outside world is cast in this mould. Building with bricks in the middle of the waiting-room indicated that Pierre felt that his body had something solid inside it so he could face the terrors of the lava-filled passage leading to the consulting-room. Thus, he did not need to flop down. He was beginning to feel that he had an inner structure which could support him and, as a result of his analyst's firmness and consistency, could feel that there was also an outside structure which could do this. T h e Tennyson verses quoted at the head of this chgpter implied that this was necessary for the sense of being an '1'. It was also necessary to avoid madness or the wrong, terrible kind of 'isolation'. Both pieces of clinical material indicate that Jean's and Pierre's impulsivity was coming under control. They were beginning to become psychologically toilet-trained. This meant that they could communicate about their terrors. Because he had a more secure sense of his existence, Pierre could begin to feel that he had a secure body image. Previously, he had felt that he could dissolve and be 'gone'. He had been a mass of body sensations with no feeling of solidity and substantiality.

The signifkance of the early body sensations T h e thesis which is being developed is that at first, the 'felt-self' is experienced in terms of fluids and gases. This is not surprising, since the newly born infant has emerged from a fluid medium and his early food and excretions are associated with fluids and gas. As Spitz (1960) has pointed out, the neonate has to adjust from being a water creature to being a dweller on dry land. This is quite a big adjustment, and it is to be expected that sensations associated with floating in a fluid medium will linger on to become part of the early body image. Autistic children often show that they feel that they are floating. For them, getting in touch with reality is felt quite literally as 'coming down to earth'. (When we become aware of

224 AUTISTIC BARRIERS IN NEUROTIC PATIENTS these deep levels, it becomes evident how much the homely sayings of everyday speech have been influenced by them.) Autistic children often walk on their toes and seem to float rather than walk. In this floating state they feel that they can perform remarkable feats such as flying, climbing to great heights, or walking on a tightrope high above the ground. Indeed, they often do some of these things. For example, Antonio, whose clinical material is to be presented later in this chapter, did some very skilful climbing to considerable heights in the early days of his treatment. Also, when I worked at the Putnam Center in Boston, Massachusetts, there was a little autistic girl who walked on a very high tightrope. Such autistic children perform these hazardous feats without any realistic sense of danger. Paradoxically, however, they are beset by fantastic, illusory terrors. For example, in their fluid, gaseous states they are afraid that they will explode or be spilled through holes. Being spilled or exploded means emptiness, extinction, nothingness. The delusions associated with autistic objects are very operative at this stage. One function of these is to seem to block up holes through which 'me-ness' can spill or erupt. The slippery smoothness of the fluid state can seem threatened by floods, waterfalls, whirlpools, eruptions and the like, which arouse primitive terror. Elsewhere (Tustin, 1972, 1981) attention has been drawn to processes which I have called 'flowing-over-at-oneness'. These processes are seen as contributing to the sense of 'primal unity' described by Freud. Two Italian workers with psychogenic autistic children, De Astis and Giannotti (1980), have shown that these early interchanges between mother and infant heal the rupture of the caesura of birth. Winnicott (1958) has pointed out that, in early infancy, interchange is based on illusion. The illusion seems to be of a continuous, rhythmical ebb and flow. In infancy this healing, cleansing flow between mother and baby can seem to be broken in a violent and catastrophic way. All infants suffer the

225 disillusionment of the Fall from the seeming perfection of continuous, silky smoothness into the broken gritty darkness of lack of perfect satisfaction in the exact terms they desire. But for some infants, for a variety of reasons, this fall from grace has been experienced as a catastrophe. This can be due to constitutional factors in the infant, or to environmental ones, or to a mixture of both. Interchanges seem to break down. T h e seamless robe of perfect perfection seems rent with holes. In neurotic children, in the terms of this chapter, the development of a sense of 'I-ness' has been disturbed, in psychogenic autistic children it has been stopped, by catastrophic happenings to the 'felt-self'. In psychoanalytic treatment we have to set these transforming interchanges going again. Dr Genevitve Haag, a French psychoanalyst, has shown us that the children indicate that these remedial interchanges are beginning to take place by drawing a cross in which two lines of equal lengths intersect each other. It is ,her finding that when they draw this, the autistic children are beginning to have a body image which has a supporting, inner bony structure (Haag, 1983). The early body sense has been illustrated by Jean's and Pierre's material. Clinical work with another psychogenic autistic child will now be presented to illustrate the working through of these states, and the more secure establishment of the body image. With this comes the development of a sense of personal identity and the use of the pronoun '1'. T H E DEVELOPMENT OF 'I-NESS'

Clinical example 3 Antonio is currently being treated by Dr Suzanne Maiello, who works in Italy and who discusses her work with me from time to time. Antonio was referred to her when he was five-and-a-half years old, and is being seen three times a week. Antonio's was obviously a severe case of psychogenic autism; Maiello records that when she first started working with him, he was completely closed up in an autistic state (1982). She writes :'His large green eyes seemed not to see, and to slip away from me and from ob-

226 AUTISTIC BARRIERS IN NEUROTIC PATIENTS jects. He practically did not speak, but produced some inarticulate sounds every now and then, and did not usually react to my interpretations.' In the fluid, gaseous, floating state which has been described in the first part of this chapter, Antonio climbed to quite high up, using the wooden frames of the door and windows to do this. He was extremely skilful and fearless in so doing. A change came when Antonio became afraid of flying birds with whom he obviously felt equated. In various ways he showed Dr Maiello that he wanted her to put them (him) in a cage, because he was afraid that they (he) would fly higher and higher and be gone. Maiello records, 'It seemed to him that it was important to remain down and inside the room where I was,' Maiello did not put her patient into a cage but, by her dedicated attentiveness, consistent behaviour and relatively unchanging setting, held him in her attention. This prevented him from slipping away from her like the flying birds. As the result of this, rewarding changes began to take place. One of these was the development of imagination and fantasy. The development of imagination As Antonio experienced being held firmly but understandingly, he virtually stopped climbing. He became aware that although he was restricted by the boundaries to the room, he was also held safely by them. He also became aware that there were closed doors to rooms into which he could not enter. This frustration stimulated the development of imagination. Sometimes he imagined that there were wonderful Maiello things in the closed rooms; at other times, there were threatening things. The development of imagination is a necessary prerequisite for the secure establishment of a body image from the early flux of uncoordinated sensations. This, and the development of memory, helps to establish the feeling that there is continuity of existence. The continuity of existence Antonio showed the development of this realization by some interesting activities with tunnels.

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Indeed, 'tunnel' was his first word. On one occasion, he used the carpet as a tunnel and crawled through it several times, as Maiello says, 'with great involvement and concentration'. When he came out of the carpet tunnel into the light after the long crawling in the dark, there was 'an expression of deep surprise on his face'. Later in treatment he did the same thing with a small toy sheep which he made go through a paper tunnel. As it emerged he greeted it with an exclamation of 'Here it is!' in a tone of both 'relief and confirmation of an expected event'. Antonio was obviously gaining reassurance that both he and the toy sheep could still exist even though they were out of sight and were not being looked at. His Berkeleyan notions were being modified. He was realizing that things had continuity of existence apart from being seen by him. The horrors and despair of non-existence were being dealt with. Thus, hope was becoming a possibility. These developments took place partly as the result of reality testing, but also through Antonio's feeling that through play, he had control over the comings and goings of things - of things being 'there' - and of things being 'gone'. A few sessions later, play developed in which he showed that he was beginning to realize that things could be out of his control, but could still exist. This concerned his interest in the water pipes.

The body image as a system of pipes Antonio became very interested in the water flowing out of the outlet hole in the wash-basin down the outlet pipe and under a grating in the floor. He also put his ear to the pipe which channelled the rush of water when the toilet was flushed. The existence of the water in these pipes could be inferred, but it could not be seen nor directly controlled by him. There were also indications concerning the nature of his body image during this period. As he was washing his foot he asked 'What is in my foot?', as if it seemed a logical inference that it too might have water pipes. A similar comparison seemed to be being made by a ninemonth-old infant described by Dr Anik Maufras de ChBtellier,

228 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S the French psychoanalyst mentioned earlier. Dr Maufras records: 'Louise had in her hands a little tube. She put her left index finger into the hole of the tube and then into her left earhole with a thoughtful expression upon her face. Immediately after that, she put her right index finger into the hole of the tube and then into her right ear-hole.' It seems tenable that Louise was wondering whether her ear-holes led to tubes in her head, similar to the tube in her hand. In an original and interesting paper, 'The notion of a psychotic body image in neurotic and psychotic patients', an Argentinian psychoanalyst, Dr David Rosenfeld, brought convincing material from adult patients to show that, in very regressed states, their body image was a system of tubes which were felt to control the flow of body fluids. Dr Rosenfeld (1981) suggests that this seeming containment of body fluids by the body image as a system of pipes is a more elementary body image than that described by Dr Esther Bick, who has written (1968) of the containing function of the skin. Dr Didier Anzieu, a French psychoanalyst, has also written of the containing function of the skin in the development of the sense of self, and coined the phrase 'moi-peau', the 'me-skin' (Anzieu, 1974). My own clinical work confirms that the body image as a system of pipes is more elementary than the image of the whole body being contained by the skin. However, the 'system of pipes' body image implies awareness of 'insides', and also awareness of outside situations and identification with them. It is a movement away from undifferentiated autism to a transitional awareness of 'me' and 'not-me'. Transitional activities are becoming possible. However, Maiello's patient was also moving from his body image as a system of pipes, to a proprioceptive awareness that his body had cohesive form and shape bounded by a skin which gave it an outline. He began to realize that his body was one object amongst other objects which had identifiable forms and shapes and distinguishing names.

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The development of a more cohesive body image When he was eight years old, and in a fit of temper due to some frustration, Antonio dismantled a toy lion which he had brought from home. This lion was made of plastic sticks assembled in such a way that it could be stretched and shortened like an accordion. After an interpretation from Maiello, based on Donald Meltzer's concept of 'dismantling' ( Meltzer et al., 1975), Antonio tried to put the lion together again. But he did it in such a haphazard way that it became 'a bizarre object' (Bion, 1962b). In the next session, Antonio took the ill-assembled lion to pieces and, collecting the parts together, put them into Dr Maiello's lap. Since he was obviously asking for help, she proceeded to put the lion together in the proper way so that it looked like a lion. However, whereas he had been able to look at Maiello making the paper tunnel through which the toy sheep had gone back and forth, Antonio could not watch her putting the concertina lion together again. He turned his back and went into a far corner of the room whilst she did it. When it was finished, he examined the put-together lion and then fetched another toy lion, which was part of the play material Maiello had provided for him, and which could not be taken to pieces. He compared it with the concertina lion and then gave it the name 'lion'. Maiello comments: 'I felt that Antonio took it as a sort of proof that an object which has been dismantled and has fallen to pieces can become a whole object again that functions properly, and can look like other objects of the same species; and furthermore that, being a whole object, it could have a name.' In fact in the following session, Antonio took the key of his drawer and detached the label which was hanging on it. He then proceeded to write his surname and Christian name on this label. However, although he said his name correctly, it was w ~ t t e nin a haphazard jumble of the letters of his name similar to the ill-assembled lion. Discussion of the lion material Antonio was obviously

230 AUTISTIC BARRIERS IN NEUROTIC PATIENTS realizing that there was the possibility of having a cohesive outside body which could be a whole object with characteristic form and shape and a name which distinguished him from other objects. However, this material poses many questions. Was Antonio realizing that two things could look alike, and could even have the same name, but could be different in certain ways? (The concertina lion was different from the play material lion.) Was he feeling that with Maiello he could feel that he was a whole boy -because she held and understood his explosive fit of temper - whereas at home he still felt that he fell apart when he was angry, and then felt that he was put together in the wrong way? (It will be remembered that the concertiria lion was from home and the other lion belonged to the play material provided by Maiello.) Why could he not look at Maiello's efforts to reassemble the concertina lion? Was it that he felt that it was a much more complicated task than making the paper tunnel and that he could not bear to look at the complication because it brought home to him his dependency on Maiello? Was it that he wanted to bluff himself that he had done it himself and, if he watched her, his bluff would be called? Was he envious of her capacity to be constructive, and wanted to negate her efforts? Did he not look because he was feeling that the concertina lion was akin to his body image, which could not be seen and could seem to be dismantled? Was the more intact lion akin to the outward appearance of his body? Was he feeling that there was a discrepancy between the illusory 'private phantom' formed from bodily sensations, which was more ephemeral than the substantial reality of his 'public body', to use Jonathan Miller's terms? T o put it in another way, was he realizing that his 'feltself' was different from his outside body, which seemed more intact and more permanent? Was a deeper idea of his bodily separateness developing? Was he beginning to distinguish more clearly between inner and outer reality? Following the lion material, the answers to some of these questions were provided by information from the parents about

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Antonio's play at home, and also from his activities in later sessions. The parents' information concerned Antonio's interest in the external appearance of his body, as distinct from his subjective proprioceptive image of it. The external appearance of the body The parents reported that Antonio would play for hours looking at his image in a long mirror and then obliterating it with soapy water. He would then wipe the mirror clean so that his image reappeared again. At first Antonio may have thought that it was another boy who appeared in the mirror, but since the parents also reported that during this period of mirror play he had recognized a photograph of himself, he must have come to realize that the mirror image was of his body. Mirrors are very magical things to children. In the world of 'through the looking-glass' all sorts of impossible things seem possible. By covering his mirror image with soapy water, Antonio could break it up and make it 'gone'; on cleaning the mirror, the image would reappear again as a whole object. Perhaps he felt that he could do the magic which Maiello had done with the concertina lion. Certainly, through this play, he could again feel in control of things being 'there', and of things being 'gone'. However, there were also reality gains from his mirror image activity. It must have been reassuring for him to find that although the mirror image became obliterated, his actual body remained. He was becoming aware of the actuality of his body, which had continuity of existence in time and space. He was realizing that he had an actual body which was different from his subjective body image. This body image was insubstantial as compared with the solid reality of his actual' body. In Kleinian terms, as well as 'unconscious phantasies' about his body, he was realizing that he had an actual, substantial body. He was developing the notion that he was a real live, substantial boy, of whose mirror image and photograph he could say 'That is me.' He was beginning to feel that he existed as an '1'.

232 . \ U T I S T l C B A R R I E R S I N N E U R O T I C P A T I E N T S The representation of himselfand other objects In recognizing the mirror image and the photograph as representations of himself, Antonio was moving towards the notion of 'selfrepresentation'. Related to this, important new developments took place in his sessions with Maiello. Antonio showed that he was realizing that if he were to make a representation of an object, the image he had in his mind had to have some consonance with the external appearance of the object, even though his representation was in a different medium. In a beautifully detailed piece of observation Maiello records this important step of progress as follows. Suddenly with great determination, Antonio fetches a sheet of paper and the scissors, and begins to cut the paper. I feel that he is cutting out something, the image of which he has in his mind. He cuts a strip of paper and then cuts it into four rectangles. He is sitting on the floor with his legs wide apart and puts the rectangles in a line in front of himself between his legs. Then he looks at the chest of drawers and copies the arrangement of its drawers, two on top and two underneath. He repeatedly looks at the original until his reproduction is perfect. Then he starts cutting more rectangles, always four from a strip. If there happen to be five of them, he throws away the fifth one. On his left-hand side, he makes other copies of the chest of drawers, with the paper rectangles. When doing the first two copies, he looks at the prototype between his legs to check that it is correct, but he never returns to looking at the actual chest of drawers to check the correctness of his representation. Finally, the other copies are done without looking at the actual chest of drawers or at the prototype between his legs. He does these last ones 'by heart' - 'from memory'. Maiello says that it was as if he had a central 'matrix'. It was

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around this time that Antonio began to refer to himself as '1'. He had begun to have a sense of self. He was no longer autistic.

The clez!elopment of mental imagery It seems tenable to assume that Antonio's body image was beginning to have more consonance with the appearance of his actual body. He was also realizing that through memory, recollection and representation, objects (of which he is one) can have continuity of existence, even though they may not be present to be seen, touched and handled. Things that have been seen and cnjoyed can, in Wordsworth's words, 'flash upon that inward eye which is the bliss of solitude'. T h e 'aloneness' of being an 'I' can begin to be tbierated. Individuality begins to become established. Later, as the glaze of complacency begins to crack and bland assumptions are given up, self-acceptance gradually becomes a possibility. But this is another story. The development of 'I-ness' in normal and autistic children T o continue with the theme of this chapter, Margaret Mahler uses the metaphor of 'psychological birth' to denote the dawning of a sense of self. In terms of normal development, she sees this as beginning in early infancy, and as going on throughout life. Antonio had to wait until he was eight years old to begin this important process, a necessary condition for which is the feeling that impulses experienced as dangerous fluids and gases can seem to be received, contained, recycled, regulated and appropriately directed, so that spontaneity is not damaged. Thus, 'waterfalls', 'volcanoes', and suchlike uncontrollable 'overflows' do not break the creative healing flow between caregivers and child. There are channels of expression for them. Emotional attachment becomes established. Emotional and co-operative relationships can begill. Until this takes place, the attempt is made to control these dangerous 'overflows' by various ineffectual means. Autistic children do it by

234 AUTISTIC BARRIERS IN NEUROTIC PATIENTS the delusion of encapsulation which shuts out stimulation; schizophrenic-type children do it by seeming to enfold themselves inside the mother and other objects; some deprived children develop a precocious use of words, and others an intellectual precocity (James, 1960). Autistic children are full of terrors and misconceptions. T h e misconceptions concern their body image and do not help to alleviate the terrors. This hampers the development of a normal sense of self. In his vivid way Jonathan Miller (1981) speaks of the normal body image as being 'the translucent glove of the possibility of self'. His BBC television series was based on findings from work with patients who had had bodily amputations or neurological surgery, as was Paul Schilder's fascinating The Image and Appearance of the Human Body (1935). This chapter has been based on findings from children whose psyche had been damaged, either by being exposed to reality too harshly and too early, or by being over-protected from it so that, in everyday parlance, they were 'spoiled'. For all these children, their body image seemed damaged. This meant that their sense of self was damaged also. It is encouraging to find that, with insightful and dedicated work, this damage can be remedied, at least in certain young psychogenic autistic children. With treatment which is appropriate to their needs, they can be enabled to work over body image processes which should have taken place in infancy. However, they do this in a somewhat different way from the normal infant. In the clinical situation, developments can be observed taking place in a slow and stilted way which occur much more rapidly and at a much earlier age in the normal infant. For example, eight-year-old Antonio's play with the toy sheep which he makes come and go is similar to the play of the eighteen-month-old baby recorded by Freud in Beyond the Pleasure Principle (1920), who made a cotton reel appear and disappear over the side of his cot. Also, nine-year-old Antonio's play with his image in the mirror is similar to the play of Freud's eighteen-month-old infant. However, in the infant observed by

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Freud, the cotton reel incident and the mirror play occurred at about the same time. For Antonio, there was a gap of one year between the two incidents. Jonathan Miller has observed that 'The body image is laboriously constructed as we move our limbs.' As infants, autistic children are very passive and do not move their limbs as much as a normal infant. This may be one reason for the elementary nature of their body image. Studying the stiff and halting development of the body image and the sense of being an 'I' of psychogenic autistic children cannot but impress us with the complexity of the task achieved by normal infants without their ever being aware that it is taking place.

Conclusion In discussing the significance of the body image in the development of a secure and authentic sense of 'I-ness', an attempt has been made to write from the patient's point of view. This has meant that this chapter has been an empathic rather than a theoretical contribution. It has sought to show that primordial states of sensation are of basic significance in the development of the body image and of the sense of self. T h e difficulty of communicating about such non-verbal states by means of words has been recognized. However, it has been felt that the needs of some of our patients drive us to make the attempt, just as their needs drive them to try to communicate about them to us. In an endeavour to understand such communications, clinical material has been presented to show that impulsivity, in these early states, seems to be experienced in such terms as rushing water or explosive bodily fluids and gases. In treatment, as the children encounter the hardness of frustration in a sane and caring setting, and as they feel that the uncontrollable 'waterfalls' and 'volcanoes' of their impulsivity are received, processed and understood by another being who has both sensitivity and robust common sense, their body image begins to feel more substantial and intact. They begin to feel that they have an inner structure, and

236 A U T I S T I C B A R R I E B S I N N E U R O T I C P A T I E N T S that there is an outer structure which helps them to bear what had previously seemed unbearable. These unbearable sensations had seemed to gush out in an uncontrollable way which had undermined their self-confidence. As these are felt to be held and contained, the children begin to develop hopefulness and a sense of purpose. Clinical material was r!so presented to illustrate the dawning of an awareness that the actual body image is a cohesive entity which has permanence in space and time. As the body image begins to have more consonance with the actual body, a more secure sense of existence an3 identity develops. T h e child begins to feel that he has a name and that he is an individual in his own right. All this is associatcd with becoming related to the therapist as the 'breast' of infancy. T h e development of mental imagery also contributes to the reassurance of the continuity of existence. Recollection, reverie and representation become possible. Thus, the 'aloneness' and the isolating 'loneliness' of being an 'I' are assuaged.

Anorexia nervosa in an adolescent girl I've built walls, A fortress steep and mighty That none may penetrate. I have no need of friendship. Friendship causes pain. It's laughter and it's loving I disdain I am a rock, I am an island.

I have my books

And my poetry to protect me. I am shielded in my armour, Hiding in my room, Safe within my womb I touch no one, and no one touches me. I am a rock, I am a island. And a rock feels no pain, And an island never cries.

Paul Simon, lyric to 'I am a Rock'

T

his lyric by Paul Simon was given to me by Jean, the anorexic patient discussed in Chapters 12 and 13. She said that it expressed how she felt. It illustrates the similarity between the states experienced by an anorexic patient and those of autistic children. Margaret, the patient who will be discussed in this chapter, experienced the primal depression which lies at the root of autism (see Chapter 4). This was my first clinical paper, written in 1958. I was treating autistic children when I was working with Margaret but, at that tirne, I had not realized the connection between anorexia and autism. However, it is implicit in the clinical material as it unfolds. Here is the paper as it was published in the British Journal of Medical Psychology (1958) 3 1 :184-200 ; some minor editorial changes have been made.

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The literature As early as 1694 Richard Morton wrote of anorexia nervosa as 'nervous consumption' and regarded the 'immediate cause of this distemper' to be in the 'system of the nerves'. T h e early papers on anorexia nervosa, notably those by Laskgue (1873) and Gull (1873), were concerned with establishing the prime importance of emotional factors in its causation. Both papers give descriptions of the strikingly consistent clinical picture presented by such patients. Later papers accept the psychogenesis of anorexia nervosa, and two important American papers, one by Rahman, Richardson and Ripley (1939) and the other by Waller, Kaufman and Deutsch (1940), demonstrated, by comparative studies of several cases, that such patients show similarity in regard to personality traits, phantasy life and the importance oi specific details in the family sitati ion, as well as in the symptomatic picture they present. In 1948 D r Clifford Scott wrote of anorexia nervosa, '... as yet little has been done to try to. trace specific connections between the symptoms and the instinctive life, the imagination and the interpersonal relations.' My aim is to try to trace such connections by describing the emotional processes which seemed to be associated with the fluctuations in weight and eating difficulties in an adolescent girl who was diagnosed as a severe case of anorexia nervosa, and which were observed in the context of a particular therapeutic technique. I shall not be concerned to advocate a particular method of therapy. Following the description of the case, the work of other therapists using different but intensive techniques will be quoted. I hope that this comparison of the material obtained in longterm treatments may throw light on the unconscious processes that are called into play in shorter forms of treatment or in the cases which clear u p spontaneously. It may also help to explain why so many relapses occur after apparent cure. T h e fluctuations in weight of my patient, and the unconscious processes which seemed to be associated with them, may also help us to understand the oscillation between anorexia and bu-

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limia which is sometimes a marked feature of these cases. It will also be apparent that although the onset of the anorexia appeared to be sudden, in actual fact the ill~lesshad a long history and was the expression of a deep-seated and longstanding neurotic disturbance. This paper is an attempt to add to our understanding of the factors involved in this disturbance. In the preparation for writing this paper an analysis was prepared of the full notes made during the first one-and-a-half years of treatment. T h e material of each session was briefly described in one column and my inferences concerning this material were summarized in the adjoining column. It is from these summaries that the following description has been prepared. A graph (p.267) was drawn to show gains and losses of weight during this period of treatment; As the description of the treatment progresses, the patient's variations in weight will be related to the unconscious phantasies which I inferred were emerging in her relationship with me. I aim to give a simple descriptive account of the work done with ohe patient, using the minimum of specialized terms, so that therapists with training different from my own will readily be able to compare their experiences with similar patients.

Clinical materid Margaret, the subject of this paper, was treated many years before I saw Jean. She was thirteen when she was first seen on 16 November 1955 in the paediatric department of a large general hospital. From there, after extensive physical investigations had revealed no organic cause for her non-eating and loss of weight, she was referred to the psychiatric department of the same hospital. Before she started psychotherapy on 9 January 1956, Margaret weighed only 3 stones 13% Ibs. She was cyanosed and the paediatric staff were convinced that if she did not get immediate help she would die. Her teachers described Margaret as a quiet, well-behaved girl. Her mother confirmed this and said that from an early age she hardly played with her toys, preserving them clean and

240 AUTISTIC BARRIERS IN NEUROTIC PATlEN7.S almost untouched. She also would not eat any food which she suspected had a speck of dirt on it. Her blood circulation was poor and she suffered badly from chilblains in the winter. She had not yet started to menstruate. In her interview with the psychiatric social worker, Margaret's mother dated the anorexia back to September 1955, the beginning of the new school term when Margaret announced that she wanted to slim because she was afraid that she would be too fat to take her dancing examination in November. She had learned ballet dancing since the age of nine and already passed one examination. She virtually stopped eating in spite of bullying and coaxing from both parents. At the same time her class were shown a sex instruction film and Margaret fainted. She said that talking about or seeing blood made her sick and that she did not wish to know about sex or menstruation. In September, too, Margaret became very interested in an aunt's pregnancy and also in that of a neighbour. Father was in the Navy when Margaret was born during the war. She was breastfed for four months when her mother's milk stopped as a result of her anxiety and distress when she heard her husband's ship was missing. She did not hear from him for three months and was very depressed during this time, although later she heard that he was alive and in good health. Margaret did not take well to the bottle and was a sleepy feeder. From then until she was ten years old she was a finicky eater. After that, Margaret still had specific foods she would not eat. One of these was sugar, which she refused after mother had explained why she herself had to have sugar to prevent her from going into an insulin conla. Mother frequently had to go to hospital to be weighed because of her difficulties in stabilizing on a diet. Mother had started to suffer from diabetes when Margaret was two years old. When she was three, father was demobilized and mother immediately became pregnant with her second child. During this time Margaret went into hospital with

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gastro-enteritis. When father first came home there was a good deal of tension between the parents, and mother said that it took them a year to get adjusted to each other. Until Margaret was six all the family slept in one bedroom. When they obtained a council house Margaret had her own room, but she was sometimes called in to help father to look after mother when she was in an insulin coma. At the time of referral the family consisted of mother and father; Margaret, 13; Robin, 11 ; Dennis, 8; Jack, 6%. Margaret and the boys were always quarrelling. Father openly said that he preferred the boys and ignored and rejected Margaret. However, when she was in hospital he visited her and brought her presents. Mother reported that she and Margaret had a very close relationship with each other, and that Margaret would tell her how she hated father. She also said that Margaret was like a younger sister with whom she could share everything. However, in the treatment situation it became clear that Margaret had strong hostile feelings towards her mother. Mother had wanted to be a dancer when she was a young girl. She had also wanted to have six children but, because of her diabetes, she was sterilized after the birth of her fourth child. Mother and father each had a close relationship with their own parents, and each expressed resentment about this attitude in the other. In short, it seemed that the family adjustment was a good deal on the basis of one section uniting against another section - boys versus girls - father versus mother - father's family versus mother's family. After the first history-taking interview neither of the parents was seen by the psychiatric social worker. When the parents were anxious they were seen by the psychiatrist who took the medical responsibility for the case. I did not see Margaret prior to the beginning of treatment. When treatment started I saw her three times a week for sessions lasting half an hour, which was the maximum amount of time 1 could give her due to my

242 AUTISTIC BARRIERS IN NEUROTIC PATIENTS full programme at the hospital. For the first two-and-a-half months of treatment she was an in-patient in the hospital; after this she returned home and came to see me on the same days as before as an out-patient. In the early days as we sat together in the often silent room I was caught up in her own despair about herself and felt hopeless about helping her. In addition, my own anxieties were intensified by those of the paediatric and nursing staff, who were very upset when she lost weight or stood still, or did not put on weight as fast as they would have liked. T h e fact that my psychiatrist colleague saw his role as that of absorbing and dealing with these anxieties contributed an indispensable part to the help I was able to provide this child.* T h e analysis of the transference relationship was the main instrument of my therapeutic work with this girl, which followed the principles outlined by Melanie Klein. This means that both the negative and positive aspects of the transference relationship were taken u p and that reassurances were not given other than the ones that were implicit in the analytic situation. I did not offer food to my patient or reassure her that it was all right to eat. I did not visit her in the hospital ward, or give her presents, or reassure her against her despair that she was untreatable and unlovable (the integration of this despair into the fabric of her personality being a therapeutic aim). However, I tried always to be on time for her sessions with me. I rarely cancelled or altered her sessions and, as can be imagined, this girl provoked much reflection in me, both in and out of the analytic situation. It will be seen that in this technique there is much emphasis *I wish to express my gratitude to Dr Sydney Klein, who took medical responsibility for this case, and was a great support to me during this girl's treatment; in particular, in seeing, his role as receiving the anxieties which came from outside sources, such as the parents, the nursing staff and the paediatrician. In this protected situation, I was free to concentrate on my own and the patient's anxieties.

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on the transference situation which is seen as evoking early preverbal experiences, particularly in the preliminary phase of treatment. It is in this phase that it is difficult to make contact with patients suffering from anorexia nervosa due to their extreme reticence and withdrawal. Although many ways exist to establish and maintain contact with such patients at this stage, in the method used here the analytic situation was not modified, and an attempt was made to keep contact with Margaret by understanding in detail the play of feeling evoked by the analytic situation and to talk about this to her in simple and direct terms. It will be obvious that in such a situation, where there is a paucity of verbal associations, other details have to be used as evidence for interpretations which are deduced from different, and in some cases more slender, evidence than that available when the patient is more verbally communicative. Thus, interpretations in this early period were based upon slight changes of posture, fleeting facial expressions and tiny hand movements, as well as on the patient's isolated associations. One difficulty in dealing with early material in this way is that an attempt has to be made to reconstruct, through the sophisticated medium of words, a play of affect first experienced at the preverbal stage of development. T h e first phase of treatment will be described in some detail in order to demonstrate initial difficulties, and to give a working example of the technique. T h e succeeding phases will of necessity be condensed to fit within the compass of the chapter. On 9 January Margaret came from the ward to my room for her first session. She was accompanied by a nurse, and, in spite of looking as though her skeleton-like body would be broken into pieces by the weight of the hospital blanket draped around her shoulders, she walked steadily and unaided. In view of her physical weakness it was natural for her to lie on the couch. I sat at the right-hand side of her pillow. Stillness

244 ,\LJTISTlC B.4RRIERS I N N E U R O T I C P A T I E N T S and immobility were the most marked features as she lay stiffly under her blanket. T h e bones of her face showed white through the blue, tightly drawn skin. I explained to her that treatment entailed her telling me any thoughts that came into her mind so that together we could try to understand why she was not wanting to eat. She made no reply to this explanation and lay looking straight in front of her. When she made an uneasy gesture I interpreted her anxiety about me as another new and strange person amongst the many new people she had seen since she came into the hospital. She made no response and continued to lie looking straight in front of her. After a long pause she spoke haltingly and in such a whisper that I had to lean forward to hear what she was saying. As I did so I became aware of the unpleasant smell that came from her body and it was only with an effort that I stayed close enough to hear that her teacher, who had been supposed to be coming that morning, had not come. I said I thought she was telling me that when she had seen these other people in the hospital she had been hopeful that they would help her, that she had been disappointed that they had not done so, and that she had not seen them again. She felt that they had raised her hopes and had then let her down, just as the teacher had disappointed her this morning. She was afraid that I would raise her hopes and then let her down in'the same way. I then told her I would see her on three mornings a week and that the days would be Monday, Tuesday and Friday. After this interpretation and explanation she looked a little less pinched and cold and gradually moved her body so that she was curled up under her blanket in such a way that a picture of a baby feeding came immediately to my mind. She stayed like this for the rest of the session. Her next whispered, halting sentence was given when she was sitting up ready to go to the ward. She said she had been weighed that morning and that she had put on 1/2 Ib. I said I thought she was telling me this so that I felt rewarded for the work I had done, and so that I would see her again tomorrow.

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This first session well shows the mixture of hope and hopelessness which was such a marked feature of this girl's analyis. The increase in weight on hearing that she is to start psychotherapy is similar to the M Ib increase which occurred when she first came into the hospital for physical investigations. In the light of her behaviour throughout the treatment, it probably occurred in response to a resurgence of hope that she had found someone who would understand her needs, only to give place to despair and loss of weight when her hopes were disappointed and she was left in the grip of her conflicts. In the beginning of the next session she did not speak but lay looking at me as she had done towards the end of the first session. It seemed very meaningful to her when I said I thought she wanted to be a baby, and that she felt she was feeding from every word that came out of my mouth. After a pause, in response to a slight movement of her body, I said I thought that she wanted to talk to me with her body as she had done to her mother before she could talk. At this she moved nearer to me and spoke in the same almost inaudible, halting voice. She said that she liked watching the dancing on television. I said this seemed to mean that although she did not like to take things in with her mouth she still liked to take things in with her eyes, as she was doing now with me. A flicker of a smile passed across her face and she continued to look at me. After a long time of looking at me, she momentarily glanced out of the window and whispered something, of which I only caught the word 'exciting'. I responded to this by saying I thought she felt that there was an exciting life going on outside the hospital, something like the dancing on television, and that I took part in this life. For some reason she only dared to take part in it by watching. After her session on the Friday of that week (13 January) I heard from the ward sister that she had started eating again and was joining the life of the ward. On Monday she weighed 1'/z Ib more. It seemed that her positive attitudes to feeding had been reinforced and stimulated by experiences in the transference

246 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S relationship with me during the week, and had affected her behaviour outside the analytic situation. It would be useful to try to analyse what these experiences had meant to her. We can infer that she felt that she had found someone who seemed willing to spend a good deal of time and trouble on her, and this flattered and reassured her against the deep fears which were to come up later that she was unlovable and worthless. She began to hope that all her needs and wishes, however unrealistic, were going to be satisfied. I suspect that my seeing her constituted a reassurance, as though I were saying, 'It is all right, I will make you better.' It soon became obvious that she saw me as a wonderful, omnipotent person who would perform the miracle of making her better and that she felt that nothing short of a miracle would do this. It also became clear later that 'better' did not mean only better in health but 'better' in a moral sense also, and that in both senses she felt out of the reach of human aid. On the other hand, very intense responses had been called into play which had their prototypes in the feeding situation in early infancy, and this had become abundantly clear to both of us. T h u s the stage was set for the continued evocation of her unconscious phantasies about feeding and the social relationships this entailed, and a reliving of her early problems through the transference relationship to me in the hope of finding new adjustments. In addition, her impulses to live had been stimulated by her interest in me and my affairs. I think the situation of being separated from her home and parents, of living the restricted life of the hospital ward, of being in bed and thus dependent upon the nurses for care and attention, of being physically so weak and helpless, and of being in a starved condition predisposed her to re-experience very vividly the babyhood feelings that we find evoked in all our patients by the special circumstances of the analytic situation. On Monday and Tuesday (16 and 17 January) she gave more associations and spoke more audibly. I gathered from these associations that she wanted to come so close to me that we were

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like inseparable, identical sisters and so did everything together. I pointed out to her that by this means she hoped that she might participate in my exciting outside life. In the Tuesday session her associations showed that she was troubled because the breaks between the session's threatened the closeness she desired and aroused feelings of frustration and anger. However, she preserved our close relationship by directing her angry feelings towards her father and her brothers. After interpretation, she saw how she behaved similarly in the family situation. On Friday I pointed out to her how she was still trying to preserve the illusion of our identical 'togetherness' by urging me to visit her in the hospital ward to stay with her there. On Monday 23 January she weighed 1M Ib more. It will be seen that these gains of weight had been possible on the basis of an illusion that she was identical with me as a life-giving, powerful person. On Monday and Tuesday, 23 and 24 January, she ceased to look at me and was withdrawn and reticent. On Friday 27 January it became clear that this was because she could no longer avoid the fact of our separateness. She said directly that in the times when I was not with her she felt that I had an exciting life .in which she could not share. It was clear that this aroused her anger. She was afraid to be angry with me and wanted to produce something to please me, but because of her feelings of admiration for me, she compared herself with me so much to her own disadvantage that she felt she could not produce anything good enough. She was constipated and, on this occasion, the analytic situation evoked the feelings she had had in the. toilet situation in childhood, when she had felt unable to produce anything good enough for the mother she admired so much. Her associations showed that examinations stirred up the same feelings, and we saw some of her reasons for avoiding the dancing examination in November. During this period the ward sister reported that she had withdrawn from the life of the ward and her weight continued to fall.

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In the following session she expressed dissatisfaction with her auburn hair and showed openly that she envied me my freedom and my pretty clothes. By comparison she felt restricted and dowdy. She wanted to leave the hospital. In the next session she showed that unconsciously she felt that I was as envious of and hostile towards her as she felt towards me. Unconsciously, she felt that out of malice and spite I neglected her (did not visit her) and restricted her (kept her in the hospital) to prevent her from growing up and being feminine. This was interpreted to her as a reactivation of similar feelings in infancy directed towards her mother. She was hopeless about this situation where we seemed to mean ill by each other, and her weight continued to fall. On 17 February her aunt came into the maternity part of the same hospital to have her baby, and on 18 February Margaret identified with this pregnant aunt to the extent of having severe abdominal pains which, on very thorough investigation by the paediatrician, were found to have no physical cause. This episode is reminiscent of the gastro-enteritis when she was three years old and her mother was pregnant with her second child. It also threw considerable light on her behaviour during the sessions previous to her aunt's confinement. I n these sessions she had made occasional references to this aunt. She had also shown great concern about the noisy rumbling in her stomach. It was now clear to me that one of her unconscious phantasies had been that I was the pregnant mother in whose exciting experiences she could share if we were identical and inseparable. On Monday she did not look at me and was very reticent. The isolated and halting associations she gave showed that she felt she had taken in my words (eaten my food) and so had been able to make progress, to put on weight, to get fatter. In her unconscious phantasy this was equated with making a baby at my expense. We now saw one of the root causes of her noneating. Ever since she had begun to eat again, she had been feeling that in secret she was growing the baby she produced in

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phantasy on 18 February. There was also material to show that she felt I preferred boys to girls. As a girl she feared I would punish her as a potential rival or as a disappointing sexual partner. We saw now that one of her many reasons for avoiding the dancing examination was the fear that her femininity would be disclosed. It will be seen later that menstruation was looked upon as a similar examination. The next session, 21 February, was an important one. Ever since she had become aware of our separateness, she had been clamouring that by such things as presents, reassurances and constant visiting (none of which in the end would have satisfied her), I should help to bolster her illusion that I was an inexhaustible source of supplies. She now faced the terrifying fact that she was dependent upon a human being who was heir to all the human frailties such as fatigue, moods, illnesses and even death. The collapse of her pregnancy phantasy, the recognition of the fact of our separateness, and, with this, the realization through interpretation of her envious rivalry and consequent hostility, the fact that she was losing weight, the observations she made in the ward which showed that the hospital staff did not always understand how to control other patients' gains and losses of weight by special diets; all these worked together to make it impossible for her to maintain the phantasy that she had found a being to care for her who knew everything, who would gratify her every wish, who was ever-present, who was never ill, never tired, never depressed, who was a source of inexhaustible supplies, whose exciting private life was unspoiled and happy, and who she could always feel was supremely well-disposed towards her. This breakdown in her omnipotence was experienced as exhaustion and tiredness. In this session Margaret became aware of her feelings of helpless dependence upon me. For the first time she recognized that if she did not eat she would die. She feared that she had exhausted my supplies of goodwill, patience and understanding (my 'food'), that I would thus withdraw treatment from her, and that therefore she would die. As well as being feared

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because of the envious hostility it aroused, separation from me was feared because it seemed to confirm her deep fears that she had exhausted me. She tried to talk a great deal but she showed clearly her mistrust of her capacity to produce anything that would revive my interest in her. I saw the feelings of this session as a reactivation of the situation at four months when her mother's milk failed and she was cared for by a depressed and unresponsive mother - a situation which had been reactivated, and the impression of it deepened by her responses to later difficult situations when, because her mother's attention had been temporarily withdrawn from her, she had feared that she had exhausted her mother's supplies of loving care and attention. Such situations would be the onset of her mother's illness, the return of her father, her mother's difficult pregnancies when she had to be in hospital a great deal, and her experience of her mother's comas. She had clung tenaciously to the phantasy of my omnipotence because if I were not omnipotent I could be hurt by her attacks and, in her imagination, I became ravaged and despoiled. If she dared to entertain the thought of my fallibility, I could die and she could die. United and identical with me as this mother, she felt possessed by an ill, almost dead mother from whose grip whe was unable to free herself. Thus she felt hopeless, exhausted and almost dead. Material in later sessions confirmed that she felt she exhausted me by her greedy demands for my care and attention, and that she had the unconscious phantasy of herself as the baby inside me who exhausted me by greedy feeding and insatiable demands for love, care and attention, and who spoiled my grown-up life by her envious greedy attacks upon it. The anxiety about these attacks was another important factor which contributed to the inhibition of her interest in food and to the restriction of her life. In the session under discussion she was in a state of agitation to produce something which would revive and replenish me so that my care returned to her; but she was desperately afraid that her productions would be ineffectual. It

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is obvious that her mother's incurable illness must have reinforced the phantasies we saw expressed in the session on 27 January that her productions were worthless and inadequate. We now saw further reasons for her fear of taking the dancing examination in November. In later sessions we came to see that her dancing was partly an attempt to satisfy her mother's own unful.filled ambitions, which also contributed to her overwhelming desire to have a baby. In some moods she wanted to satisfy all her mother's disappointed wishes. Her dancing was also an attempt to bring her depressed, dead (comatose) mother to life. It had its roots in the dancing up and down which she had done on her mother's knee and which had pleased and cheered her. Since all movement was equated with life it came to be looked upon as a life-giving activity and was elaborated into her masturbatory movements from which dancing was a derivative. From earliest times her uncertainty had been whether she could (and should) grow, move forward, dance, be lively, be 'playful' (her own association to feeling better); or whether she should stand still, regress, depress her playfulness, stop growing, die. T o decide to grow and to live, among other things, meant draining her mother's resources and facing the problems that this created for her. It also meant satisfying her feminine impulses and, besides bringing her into rivalry with her mother, disappointed some of her mother's wishes. In her treatment she again faced these problems in the transference relationship with me. Her agitation in this session was over how she could get the care and attention she needed because of her helpless dependence, without draining me of all my supplies and without arousing my frightening envy and hostility. In the next session she dealt with this problem by becoming the submissive, docile child. Her angry, greedy, biting impulses were seen in another girl in the ward who was 'naughty and bit Sister'. Her rebellious feelings were inhibited and I was seen as the mother who quite rightly restrained this child who was liable to be so destructive. She was shocked by her biting

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impulses and submitted to restraint out of terror of the possible consequences of her greedy and destructive wishes. In this fear of her biting impulses we have another potent cause for the restriction of her eating. This adjustment, although unsatisfactory, allowed her to feed from me so long as she did not bite. Thus she kept me unused and untouched, as her mother had described how she had preserved her toys in childhood. Also during this time she told me that she rolled the food around in her mouth until it was soft enough to be swallowed, i.e., she did not bite. In the few weeks that remained before the Easter holiday she again put on weight, and it was decided that she was strong enough to be discharged from the hospital ward to continue treatment with me as an out-patient. It will be seen from the graph that during the holiday her steady progress was continued. This happened during every long break in treatment. It was noticeable that before a holiday she always made great efforts to adjust her relationship with me so that she left in a mood in which the unconscious phantasies of our having a good reciprocal feeding relationship were uppermost. It became clear that she could tolerate separation if she was sustained by the phantasy that we each drew upon an inexhaustible source of supply which meant we could feed, restore and replenish each other endlessly. Her idea of a 'good' relationship was one in which we gratified each other endlessly. When I frustrated her wishes, however unrealistic they might be, I became the epitome of all that was malicious, spiteful and restrictive; for example, when I was guided by the paediatric staff as to when she could leave the hospital. She responded by revengeful, punishing behaviour and then she felt we were locked in a destructive relationship that boded ill for both of us, and from which she feared there was no escape. She mistrusted our intentions towards each other and unconsciously feared that I would poison her as she felt she poisoned me. In these periods she lost weight presumably because she feared to eat.

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If, on the other hand, my behaviour made her feel that I was fitting in with her wishes, she responded by feeding me as she felt I fed her and by putting on weight, which, when she did so, was felt to be something that could be offered to me as a gift. For example, on 18June I suggested that she should come twice a week and that she should try to do without the Friday session. It will be seen from the graph that there was a great loss in weight following this deprivation. On 2 July I reinstated the Friday session fearing that I was putting too great a strain upon her, and because I could not cope with the feelings that were aroused. She immediately responded by drawing a bright, cheerful and connected picture of a table laid for tea. (she had started to draw in the second phase of her analysis. Her first pictures had been of stiff, isolated but whole objects, with no apparent theme, similar to the verbal associations in the early sessions.) After she was weighed on the following Monday she told me with great pride that she had put on 1%Ib. At this time, when the relationship was 'good', she felt that, quite concretely, we gave each other weight. When it was 'bad' she felt that we took it away from each other. She talked a great deal about her mother's periodic weighings and showed that she felt she was in rivalry with her mother in this area also. It became increasingly clear that she was seeing me as a person with two distinct facets. Sometimes I represented the lively, 'playful' mother of her phantasies who had a healthy body from whom she wanted to feed. At other times I was the depressed, unresponsive mother with the ill body from whom she feared to feed. Her infantile desire for closeness, which was sometimes expressed as wanting to come right inside me, or that 1 should go right inside her, meant that she felt she had taken into her body my moods and state of health as well as my exciting life. If she felt identical with, or inside me, as the creative, healthy, responsive mother whom she could refresh and revive by her effortsand who refreshed and revived her, she grew and moved forward. This meant progress and life. On the other hand, if she felt identical with, or inside me, as the

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incurable, depressed, exhausted mother whom she depleted and attacked and who attacked and depleted her, then she felt unable to grow up. This meant regression and death. These two aspects of herself, and of the mother she felt she embodied, were brought together and expressed in a tic-like gesture of hands and body. She would come forward towards me with a fluttering movement of her hands, and then fall back stiffly with her spine rigid against the back of the chair. , Her associations during this second phase of her analysis showed that she felt that the loving relationship, in which we were so close that we were inside each other, could all too easily slip over into being the possessive imprisonment associated with the greedy, destructive relationship and from which neither of us could escape. Her associations began to show that in this latter type of relationship she felt that we were one inside the other greedily and enviously biting at the contents of each other's body, particularly the penis. Progress again could only be at each other's expense and the one who made progress made it at the cost of leaving the other depleted and dying. Her ultimate fear was that we should both be left exhausted and dead. There was vivid material in which she showed that she felt that I was a 'condemned' mother whose inside was 'unfit for babies'. There was also material about her successful dancing companions who were 'in shows', and we began to see that, in her unconscious phantasies, 'shows', examinations and menstruation were equated and feared. Menstruation was felt to be another examination which she feared because of what it would show. It could not be welcomed as a sign of growing up and of her hopes of having children, since it was felt to be evidence of her own and her mother's disappointed hopes that she was a boy. As with the pseudo-pregnancy it brought into the open her secret rivalry with her mother, and was also felt to be achieved at the expense of leaving her mother incurably ill, bleeding, exhausted and even dead. It was also feared because it would reveal the 'bleeding mess'

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in her own inside which, in her unconscious phantasy, she felt was the result of her secret internal biting of the mother she had condemned to imprisonment there. In addition, it confirmed her worst fears that her own inside was bleeding and a place that was 'unfit for babies' as the result of being identical with a mother whom she had attacked in such envious and hostile rivalry. Evidence from the analysis was now coming together sufficiently for us both to be able to begin to understand why the anxieties associated with the events described by the mother in the history-taking interview, and experienced at a critical time in her development, had been so overwhelming as to precipitate her into an illness which represented a life-anddeath struggle about growing up. Up to this state in her analysis her unconscious conflicts about growing up had been expressed mainly through her body in such things as gains and losses of weight, and the tic-like gesture I have described. Her unconscious feelings of rejection were expressed in colds which occurred on the days when she did not see me. Before the end of a session, her eyes would water, but she showed none of the other physical signs of tears and gave no sign of having the emotions associated with weeping. She would say in explanation that her eyes always watered when she felt cold and this could even happen when the room was warm and she had no cold. Throughout all this time she had related to me on a fantastic and unrealistic basis and her progress was insecurely founded. It was not until September and October that a crisis in her relationship with me modified her repeated patterns, and she began to relate to me with more realism in her perception of both of us. I propose now to give the material of the September and October sessions in some detail. The crisis began with a session on Friday 21 September when she came looking pink and vivacious. She said she had started a ballroom dancing class which met on Friday evenings, and she wondered whether her Friday appointment could be changed and whether she could leave early that day. I let her go early, and unfortunately,

256 . 4 U T I S T l C BARRIERS I N N E U R O T I C PATIENTS accompanied by a colleague, I boarded the same bus as my patient, who felt very rejected by observing my relationship with someone else. T h e Friday appointment had become increasingly inconvenient for me, and, in the light of her request, I made other arrangements for the Friday and freed other times for her. On the following Monday, 24 September, she came looking pale and depressed. (Her weight was 71 lb, which was the same as the previous week.) She said that she had a cold and had earache in her left ear which made her deaf. As we sat down in our usual places (we now sat side by side) it turned out that the deaf ear was the one that was nearest to me. It seemed very meaningful to her when I interpreted that she was shutting her ear as she had shut her mouth in babyhood, because she wanted to reject my food; she felt I had rejected her by letting her go early on the Friday and by having a relationship with someone else. T o hear this interpretation she turned her head so that her other ear was towards me, but after this she said her earache was better and she listened to me with her left as well as her right ear. We then discussed the Friday session and it appeared that the dancing class started later than she thought and that she could now use the Friday time. I explained that I had now filled in the Friday time and offered her several others. She gave reasons why she could not manage to use any of them and decided,to try to do without the Friday session. It was typical of her behaviour that if I could not give her the exact thing she wanted, she could not let me have the satisfaction of giving her a satisfactory alternative. In this case she left me feeling anxious and guilty about a situation which she herself had created. T h e next day, Tuesday 25 September, she said her cold was better but she looked thin and pale. She talked fairly freely and for the first time her associations were concerned with the work she wanted to do when she left school. She also talked about a former friend who had come to live near her and with whom she wanted to renew the friendship. ( U p to now she had no close

257 friends.) Towards the end of the session she gave me a long association, talking with a new fluency and describing for the first time an incident in her childhood. The gist of this story was that she had nourished the illusion that she could help herself to things in shops, and she suddenly found out that she had to pay for them. Her eyes glinted with amused resentment when she thought of how mistaken she had been. In this session she also showed that she was grateful for the help she had had from treatment, and that her mood was one in which she was feeling disillusioned with me in the same way as she had done about the shop. She had had the phantasy that we were completely at each other's disposal. By seeing us both as equal in this way she had avoided all feelings of envious comparison and of dependency. She was now feeling that I possessed certain things that she would like to have and recognizing that she had to be willing to spend something (to suffer some frustration) to get them. On the following Monday, 1 October, she had lost 1 Ib in weight and on 8 October she had a cold and saw me as a hard, punishing, retaliatory mother who had taken away the Friday session to punish her for going to the dancing class and for having a life of her own. It became clear that one of her reasons for asking to leave early for the dancing class, and for mistaking the time it began, was that she still had a grievance about the earlier occasion when I had suggested that she should try to do without the Friday session. She hated and feared the feeling of being dependent on me, and wanted to triumph over me and to show that she was now developing an interesting life of her own. These feelings of grievance, of rivalry and of triumph conflicted with her feelings of gratitude and the desire that I should have pleasure and freedom. On 9 October the tic-like movement had returned and her associations showed that she was again in conflict about whether to make progress or to regress. (It will be seen from the graph that her weight stood still.) On 15 October her weight was unchanged. Her associations were concerned with the former friend she had mentioned on 25 ANOREXIA NERVOSA IN AN ADOLESCENT GIRL

258 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S

September. She wanted to get in touch with her but feared a snub. She then showed that she had similar feelings towards me. She wanted 'to take the plunge' and to risk the pain she feared if she allowed herself to experience loving feelings towards me. She also wanted to sleep with me as on one occasion she had slept with her girl friend. On the following day, 16 October, her mind was full of her brother, who had come into hospital for a tonsillectomy. I was seen as associated with the surgical activities of the hospital and she had strong unconscious fear's that I would cut into her and take away parts of her body; this being in retaliation for the predatory attacks in which she felt that, among other things, she had cut out the baby brother from my pregnant body. If I talked about this she winced as though I were actually doing it to her. Her eyes watered copiously and she had pains, first in her throat and then in her back, which went away after I had interpreted her fear that I would attack her. This was a dramatic session and we began to see that to some extent she was re-experiencing fears which had originated and been elaborated from situations when she had been bathed, dressed and toileted by her mother and had felt very afraid that parts of her body would be taken away. In one way, my acceptance of the situation where she had no Friday session had seemed like an attack upon her - an attack which was aimed at all her sources of pleasure. At the end of the session she told me how her aunt's baby 'cried and cried' when her aunt went out of the room. She nodded in intense agreement when I said that she was feeling that she 'cried and cried' because it was the end of the session. Her eyes were watering as she did so, but she had no other signs of weeping. During this week she lost 1 lb in weight. On the following Monday, 23 October, her associations were about leaving school and what work she would do. She had been to tea with the friend she had mentioned previously. On another occasion she had worn lipstick. All her associations

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were in this vein of growing up, having a life of her own and daring to be feminine. It will be seen on the graph that during this period, 21 September to 24 October, her variations in weight reflected the swings in mood she felt towards me. On Tuesday 24 October she again talked about her brother's tonsillectomy, and again I interpreted the unconscious fears that I would cut into her and take away parts of her body. The deprivation of the Friday session had aroused feelings associated with the frustrations she had experienced in babyhood, and her unconscious phantasies were concerned with biting her way greedily into my body to take out the desirable supplies I had there. Her unconscious feelings were that I had done the same to her. On previous occasiotls she had dealt with the recognition of the 'bad' relationship she felt to be going on between us either by projecting her aggressive feelings, or by using all the facts she could muster to bolster up the unconscious phantasy that we could each create inexhaustible supplies that were readily available and with which we could replenish each other endlessly. But on this occasion, as I interpreted to her, she put her head on her arms on the table in front of her and sobbed bitterly. She was obviously experiencing painful feelings of sadness. As her sobbing subsided, she said as she wiped her eyes: 'It's that I'm afraid I shall always be like it.' It will be seen that when she came on the following Monday her weight had increased by 2M lb. From then onwards her increases were steady until normal weight was achieved. After this there were no undue fluctuations in her weight. The tic disappeared and she had no more colds during the rest of the year, although the colder weather was now upon us. She did not have aches and pains during her sessions. Her eye-watering ceased, and in situations where this had formerly occurred she cried with all the other physical signs associated with weeping and as though it were associated with emotion. Her associations in the sessions immediately following 24 October showed a new

260 AUTISTIC BARRIERS IN NEUROTIC PATIENTS attitude of mind of being able and willing to tolerate psychic pain for a desired outcome, i.e., she now operated more according to the reality principle as described by Freud in his paper 'Formulations regarding two principles of mental functioning' (191 1). This institution of the reality principle was achieved at the critical point in development when the patient realized that both hard, frustrating experiences and soft, comforting ones emanated from the same source. This seemed to be an elemental forerunner of Klein's depressive position. This integration did not mean that the analysis entered calmer waters (Bion, 1953). Margaret began to show more openly and to experience more directly the mood swings and conflicting feelings she had previously expressed through somatic rather than psychic channels. She began to show the neurotic behaviour of which the anorexia had been a physical expression, and against which it had been a defence. Material came up to show her terror of and guilt about her sexuality. There was a good deal of material about her blood circulation and its association in her mind with menstruation. There was also material concerning her sexual wishes towards her father and her desires to have a penis. She suffered from sleeplessness and found it a great effort to come to analysis. However, she always manged to come, and her material was easier to understand in that she talked more coherently and fluently. Her life outside became fuller and more interesting. Her school achievements were of a higher standard than they had been before her illness, and she scored 90 per cent in a typewriting examination, which meant that she was top in her form in this subject. On leaving school she secured a post in an office where she seemed to have friendly relationships with other girls, although these seemed to some extent to be dependent on having one girl who was her bZte noire. After starting work she continued treatment with me on a once-aweek basis. This involved a long bus journey to my home instead of the hospital, but she managed to come in spite of a

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good many obstacles, although she still had phases when she felt very hostile towards me. She weathered the crisis of a pregnancy and subsequent long illness on my part and, at the time of writing, is coming to see me once a week. The current problems Are centred around her menstruation, which has made a tentative beginning but is not yet regularly established.+ This case demonstrates very well those features of personality, emotional preoccupation and family situation which the earlier writers showed to be so typical for anorexia nervosa. There is the family where there is an exaggerated concern about food (in this case because of the mother's diet), there is the feeling of not being wanted by one of the parents, and there is the intense rivalry with her brothers. Prior to treatment, Margaret presented all the personality traits which had been described as typical for patients who develop this illness. She showed the stubbornness, the scrupulous cleanliness, the reticence, the withdrawal, the difficulty in making friends and the intense retreat from sexuality. In addition, she illustrates the predisposition of adolescent females to develop this disorder, although cases of boys have been reported. Her symptoms of non-eating and loss of weight were associated with the other typical symptoms - inhibition of menstruation, gastro-intestinal disturbances, poor circulation and vomiting. In the treatment situation she showed the 'obsessive, compulsive and depressive' features described by other writers. She was also preoccupied with the pregnancy fantasies? which she acted out through her body which the early psychiatric investigators found to be so characteristic. She also exhibited other fantasies and details of family pattern which were not in the earlier descriptions. Her material will now be compared with that of other cases *This patient is now happily married and has two children of her own. tIn this paper I use 'fantasy' for conscious processes, 'phantasy' for unconscious ones. I t is sometimes difficult to tell the difference between the two.

262 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S who were treated by long-term, intensive therapeutic methods to see if they exhibit similar features. In one case treated along the lines of a universal collective unconscious, the therapist (von Weiszaecker, 1937) came to the conclusion that 'one of the various ways in which patients might deal with conflicts about their relationship to the mother and father, to imprisonment and freedom, to pregnancy and sterility, and to life and death was by becoming anorexic.' In 1943 Lorand reported a case treated by classical psychoanalysis. His patient was in her early twenties. He says: In this patient this symptom complex seemed to indicate a serious disturbance. It was an expression of many conflicts besides those which referred to the sexual sphere - which some investigators maintain is the outstanding or main symptom. There was deeper struggle going on within the patient - a struggle involving not only fight and defence against sexual drives, but drives which were more diffuse and pertained to disturbances in the whole personality structure. These referred mainly to the very early period of the patient's attachment to her mother, and successful therapy resulted from the solution and working through of this early attachment in detailed analytic therapy. In her early childhood she remembers being like a little beast who wanted to eat up and tear up everything and everybody. The desires which primarily concerned the mother's breast, food and getting love from the mother became in later stages identified with desires to have everything the mother possessed, including father's love. This in turn was associated with early ideas of oral impregnation. In another place he says: 'At times she felt herself like a cannibal having the desire to strangle, to yank out the penis.' He also says: 'From the therapeutic aspect, depression is one of the most difficult symptoms to handle, and is responsible for the strong wish of these patients to die.' In a paper published in 1945, Emmy Sylvester describes in

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fascinating detail her play analysis with a four-year-old child who showed acute symptoins of psychogenic anorexia. She writes: 'During the first period of her treatment her intense wish for gratification by way of undivided possession of a mother figure was clearly expressed.' Later, after a detailed description of the child's play with a doll, she says: 'However, the significant point is that the rage against the pregnant mother evokes these phantasies and these are benevolently modified only when the analyst lovingly repairs the mother doll.' Later she shows '. her envious, aggressive, incorporative attitudes towards the males of the family ... in order to be as close to mother as they are and to have their advantages'. During this time she modelled a mother doll 'with both titties and stickies'. She then became like a baby, 'a level at which gratification was not yet endangered by her hostile competitiveness ... The following period is characterized by new phenomena of egogrowth when her depressive reactions to the first separation from the analyst are worked through.' Emmy Sylvester summarizes thus :

..

Her neurosis showed the characteristics of a depression. The conflict arose on an oral level from her inability to integrate incompatible libidinal and destructive tendencies, both of which were expressed through incorporation. The decisive process in the treatment was the strengthening of the ego to an extent that enabled her to separate her loved and hated objects, and to deal with them differentially on a realistic basis rather than on the former basis of a delusional fused incorporation. Dr George Gero (1953) describes his work with a female adult patient who had a history of longstanding eating difficulties and phobic symptoms. The anorexic symptoms went back to her fifth year, when her mother gave birth to a much-desired boy child. He describes the girl's struggle against accepting her feminine role, her dissatisfaction with her body, and her comparison of her body with her mother's. He says: 'The body

264 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S

image of the mother was split into two contradictory aspects; from one point of view it represented the powerful body with the magic quality of growing things in her body, while from the other it appeared as a destroyed bloody mess.' Later, he says, 'Sometimes during the sessions she expressed the desire to take me in, the whole of me - that is, she wanted to eat me up.' He later refers to this as the 'libidinal need to merge with the object'. In contrast to this 'she experienced hostile, tearing and directed against the penis.' T h e patient biting impulses brought material which made him conclude that 'the drive pattern to tear something from the mother's body and eat it, in this patient at least, was clearly related to her penis envy.' H e concludes by saying: 'A complicated set of factors, not all of them necessarily recognizable, will decide whether or not an eating disturbance results.' We are still far from understanding the complicated set of factors which determine the life-and-death struggle we see taking place in anorexic patients, but each reported case confirms or adds to previous data. From the foregoing review, although each therapist presents the material within the concepts of his own theoretical framework, we can see that even when we drive our investigations deeper, there is still a striking similarity in the material presented by such patients. In particular, we see the major role played by the early longing for a close relationship with the rnother and a craving for the contents of her body, including the father's penis and with it the mother's exciting relationship with the father. In my patient this led on to the fantasies of imprisonment mentioned by one other therapist. This review also brings out the importance of the early conflicts in relation to the mother's body, and the failure of such patients to come to terms with the contradictory aspects of their own impulses and of the mother with whom they so closely identified in infancy in the bodily way characteristic of that early period. We see that they have not achieved a stable capacity to tolerate the depression that arises from the fact that

...

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potentialities for contraries - such as presence and absence, frustration and gratification, love and hate, restriction and freedom, life and death, creation and destruction, health and sickness, hope and despair, fruitfulness and sterility -coexist in one and the same person. The material would seem to indicate that the way in which they come to terms with this conflict determines the stability of their adjustment. When Margaret increased her capacity to bear the depression and anxiety associated with bringing these contradictory aspects together, her progress became more stable and she was more able to experience the reality of my feelings as well as her own. The depression that arose at this stage was different from the depression that came from the breakdown of her feelings of omnipotence earlier in the treatment. In the later depression she was far more in touch with the complexity of her own feelings, and had marked feelings of guilt and sadness about her capacity for cruel and invidious behaviour, together with a sense of responsibility for her actions. Edward Bibring (1953) has described in detail the earlier type of depression and has traced it back to the 'infant's or little child's shock-like experience of the feeling of helplessness'. Sylvester is the only writer to give details of the babyhood history of her patient, who, interestingly enough, was reported to have been weaned at four months (as was my patient). In both cases also the father was absent during babyhood. It may be that overwhelming disappointment in the early relationship with the mother, followed by a similar intense disappointment with regard to the father, leads to the development of anorexic symptoms in individuals who have certain constitutional predispositions. The fact that the baby had an unusually close relationship with the mother which was disturbed by a sudden appearance of the father may also be important. Dr Sylvester's case may throw light on.why this disorder occurs so frequently in adolescence. In her case, after the early weaning, the baby's development was accelerated and she became a model baby. At thirteen months she developed

266 AUTISTIC BARRIERS IN NEUROTIC PATIENTS measles, which coincided with her mother's return from hospital with the new baby. After this she lost weight, gave up walking, resumed wetting and soiling, and had temper tantrums when her mother nursed the baby. Mother dealt with this strictly and, at two, she again became a model child. When she was three years old the father returned and the patient, who until then had slept with mother, reacted violently to being turned out by father. When she was four years old and the mother began a further pregnancy, she responded by becoming cranky, disobedient, babyish, and then severely anorexic. It would seem that the adjustment to the complexity of her emergent feelings by obsessional and compulsive mechanisms breaks down with the uprush of feelings caused by her mother's new pregnancy. In adolescence the intensification of the instinctual drives would have a similar result in patients whose innate predisposition and early developmental situation predisposed them to anorexia. The material would seem to suggest that, for some reason, integrations which result in the development of the capacity to accept the reality pri~lciplewith regard to psychic factors, particularly the depressive feelings associated with loss, have never been securely established. The graph which follows illustrates that as these integrations became established, Margaret's extreme oscillations of mood were stabilized. A 'rhythm of safety', as the patient who is described in the next chapter called it, came into being.

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75

g -

70

2 (15

or 2 4

60 S5

so

Scpt, Oct. Nov. I)ec, Jali. Fch. hlar. .Apr. hlay June Jut!. .Aug. Scpc. Oct. No\. I)ec.

16 November 23 November 29 November-29 December 2 January

9 January 20 February 26 March 26 March -9 April 9 April 21 May 28 May 30 July

Seen in paediatrics department Admitted to hospital Physical investigations Seen by psychiatrist -told she is to start psychotherapy Started psychotherapy Aunt in hospital to have baby Discharged from hospital ward Easter break Returned to school Weekly weighing recommenced Whitsun break Summer break commenced

Pevsonal data

Date of birth: 2 March 1942 Age on referral : 13 yrs 10 mths Height: 5 ft 2 in Estimated normal weight (as reported by mother) : 80 Ib

CHAPTER FIFTEEhT

T h e rhythm of safety And came on that which is, and caught The deep pulsations of the world, Aeonian music measuring out The steps of Time - the shocks of Chance The blows of Death. At length my trance Was cancell'd, stricken thro' with doubt. Tennyson, In Memonam,XCIV

his chapter was originally presented as a paper to a conference in Paris organized by the Continuing Education Seminars of Los Angeles. T h e neurotic adult patient discussed in it was one of those seemingly perennial patients whose functioning is based on the avoidance of endings. Insights derived from my work with autistic children have released this patient from the fetters of her autistic practices, so that she has become able to generate fundamental understandings which have made termination a reasonably safe possibility for her. Clinical work which is influenced by psychopathology as elemental as childhood autism is bound to seem strange to those psychoanalysts who work in terms of ego psychology. It may also seem somewhat different, at least in the early stages, from clinical work which has been influenced by Melanie Klein. T h e influence of Bion and Winnicott on the chapter will be apparent. With this introduction let me present to you the patient who is the subject of this chapter, Ariadne.

T

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The patient Ariadne was first referred to me at ten years of age for learning difficulties. As a result of this childhood treatment her capacity co learn in a formal way improved, but I never felt that I was in touch with her very fundamentally. At thirteen she went to boarding school. At age twenty-five, on her own initiative, she returned to me for more psychoanalytic help because she had had a very frightening panic attack in which she had gone cold and frozen like a corpse. She had spent the whole night begging the woman friend who was with her to take her to mental hospital. We arranged that she should have two sessions a week. A dream which started off the train of thoughts to be developed in this chapter occurred after Ariadne had been back in treatment for three years. Although both she and I were concerned that she should be able to finish treatment, we never seemed to reach the point where it seemed safe to do so. The dream and the understandings it stimulated to both of us have now made termination a real possibility.

The dream The dream occurred in a session following a five-week interval during which, for various reasons, we had been unable to meet. In the dream, Ariadne was going happily towards an interesting, characterful house in which she knew that both her grandparents and great-grandparents had lived, and where her parents lived now. However, before she could reach the house, she found herself in the chasm of a huge black wave which was arching over her. The arch of the wave had glistening black ribs of water, in which there struggled drowning people rather like the people in a Hieronymus Bosch painting. The wave was so high that Ariadne could barely see the white crest on the top. She was terrified that it was going to engulf her. This dream brought to my mind the remark Ariadne had made when we had both realized that because my lecturing trips abroad would be followed by events in her own professional life, there would be an interval of five weeks before we could

270 AUTISTIC BARRIERS IN NEUROTIC PATIENTS meet again. She had asked anxiously, 'Won't that break the continuity?' As an infant Ariadne had had an overly caring mother who had been grief-stricken as the result of the death of an earlier boy child. This caused the mother and the infant Ariadne to have an unduly close association with each other from which the father had been virtually excluded. Ariadne had remained over-dependent on this mother who had been used as her constant prop, support and stay. This over-dependence had been transferred to me. In the session I reminded Ariadne of her anxieties about the breakdown in continuity caused by the five weeks' interruption of our meetings. I said I thought that the undue closeness to her mother, as an infant and small child, had engendered false hopes that her body was continuous with that of an external, ever-present mother and so could never come to an end. When she could no longer avoid awareness of their bodily separateness from each other, she had felt catastrophically let down. She had realized that she was mortal and that her body could come to an end. Since then, she had spent her whole life trying to reinstate the delusion of bodily continuity with this everlasting mother. T h e difficulty was that she was forever hoping that I was this immortal being, and she tried to manipulate the analytic situation to give credence to this belief. She did this because her whole sense of existence and of identity seemed dependent upon bodily continuity with an immortal being who went on forever. T h e recent five weeks' interruption to the continuity of coming to see me had re-evoked the catastrophic infantile experience of finding that her body was, in fact, separate from that of the mother. It was possible that her going to boarding school, which had interrupted the flow of her first analysis, had been a similar re-evocation of what she felt to be an irremediable wound. (As I hope to show later, this feeling of irremediableness came from her lack of belief in the creative inner forces of healing.) In the session I went on to say that the five

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weeks' interruption had made her feel that I had left her in the lurch of a huge black wave of tempestuous feelings which had threatened to overwhelm her. After this session I realized that in going towards the house in which her forebears had lived, Ariadne was beginning to see herself as part of a continuous process of generation succeeding generation. This would have been a compensation for giving up the unrealistic notion that her individual body could go on forever without ever coming to an end. However, this movement towards seeing herself in perspective as part of biological, evolutionary and genealogical continuity had been abruptly broken by the upsurge of overwhelming terrors about her personal survival. In the elemental depths, Ariadne did not 'think' about death; she experienced it in a sensation way. This was not the threat of death as we know it as an objective fact about what happens to people. It was a horrifying sense of bodily discontinuity which brings rage, grief and terror of endings. The body seems to come to an end in a fulminating way. The child feels forever at risk. T o get some sense of safety, there is a reaction to re-establish the delusion of bodily continuity with an everlasting 'being' who is for them alone. This 'being' is not shared with a father or other children. It is difficult to find words for this elemental phenomenon; it is sometimes called 'the environmental mother', and sometimes 'the earth mother'. It is a 'being' who is felt to guarantee the child's own sense of being. These are 'all or nothing' states. Everything is total and forever. Ariadne was freeing herself from these constrictional autistic delusions. Let me describe this more realistic forward movement, which she called a 'rhythm of safety'. T h e rhythm of safety In my reflective preparations for Ariadne's next session, I read James Grotstein's paper about primitive mental states in borderline patients (1980) and was struck by the phrase, 'the

272 AUTISTIC BARRIERS IN NEUROTIC PATIENTS infant must develop a sense of safety from its primary background object of primary identification.' 'Yes,' I thought, 'what Ariadne has lacked is a primary background object of safety.' (Since then, I have also come upon Joseph Sandler's paper on the background of safety ( 1960).) However, Ariadne had also been reflecting on this matter of safety for, as soon as she was on the couch, she said thoughtfully, 'You know, over the past week I think I've developed a rhythm of safety.' I was surprised and delighted, both by this insight and by the phrase she had used to describe it. I asked her to tell me more about it. Ariadne went on to tell me a dream she had had following the session about the black wave. She had been in a very constricted space and had thought to herself, 'I must get out of here.' She had looked for a way out and had seen a chute down which she slid. But this sliding did not bring her to safety. Metaphorically speaking, she went out of the frying pan into the fire, for sheround herself in a large amphitheatre which was full of extremely evil people. She thought to herself, 'I can't possibly walk through this place.' However, although she was very frightened, 'taking her courage in both hands'-significant phrase - she had walked through the evil amphitheatre to the other side; whereupon she had said thankfully, 'I've got a rhythm of safety.' The way in which she said this made it sound like a paean of thanksgiving. I suggested to her that having the courage to face her fear, instead of her usual practice of sliding away from it, had enabled her to become aware of resources within herself that had helped her to cope with it. Let us think about the possible origins of this 'rhythm of safety'. Ariadne's use of the word 'rhythm' brought to my mind a tape recording made by a former student of mine, of a baby feeding at the breast in the first two months of life. At first the baby could not co-ordinate the rhythm of its own sucking and breathing, so that it synchronized with the pulsing rhythms of the milk from the nipple of the breast. However, as the baby's muscular co-ordination improved, and as the mother got to

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know her baby, mother and child adapted to each other. From the baby's rhythms and from the mother's rhythms, a new rhythm developed. It was a 'creation' they had made together. The student commentator records as follows: 'The baby's mouth formed a safe hermetical seal around the nipple of the breast so that mouth, tongue, nipple and breast worked together and a synchronized rhythm came into being.' In Ariadne's terms, the infant developed a'rhythm of safety'. Brazelton speaks of mother and baby interacting with each other to create what he calls 'a reciprocity envelope'. Fortunately, due to the flexibility of human nature, this infantile interactive situation can be created in later life. This is especially the case in an analytic situation in which the use of the 'infantile transference' is understood. The primitive mind works in terms of correspondences, clang similarities and analogies. In certain states, the analytic experience is so deeply felt that it feels analogous to the baby feeding at the breast. For the 'rhythm of safety' to occur, Ariadne had had to develop an interactive reciprocal relationship with me which had deep infantile roots and in which the upright father element came into focus. This father element is hinted at in the 23rd Psalm, which is dealing with these elemental levels. You will remember it says: Yea, though I walk through the valley of the shadow of death, I will fear no evil.. . thy rod and thy staffthey comfort me. (my italics) Ariadne's behaviour, in which she used the phrase 'rhythm of safety', indicated that a deep, reciprocal relationship with me was developing. It was unusual for her to plunge straightaway into a deep discussion as she did on this occasion. The previous pattern of most of her sessions had been that she would tell me in minute detail all that had happened to her since we had last met. This helped her to feel that we had not been separated and that our bodily continuity was re-established. It had other satisfactions also. She was a charming and amusing raconteuse, and by thus capturing my interest she

274 AUTISTIC BARRIERS IN NEUROTIC PATIENTS hoped to ensure that my physical presence would always be with her. However, on the day when she, reported the development of a 'rhythm of safety', a reflective interaction developed between us in which she recognized more fully than ever before that I was separate and different from her. For one thing, she recognized in a deep way, and not merely verbally, that the five weeks' gap had arisen from our mutual adaptation of each other's activities. Between us, we evolved the phrase 'adaptive reciprocity' for this way of responding. Ariadne realized that this was very different from the 'me'-centred, mechanical routines which she had valued so highly. These had consisted in expecting the sessions to occur with clockwork regularity, in coming precisely on time, and of going through the same procedures each time she came. I had often pointed out to her that such expectations arose from the notion that I was part of her body like the beating of her heart. As a child and adolescent, Ariadne had been addicted to romantic women's magazines, and she reacted to me as if I were her 'heart-throb' forevermore. This sentimental, individualistic and body-centred notion was now being replaced by a rhythm which was the creation of both of us. It was a shared experience. This was a much better protection against the evil that she now became aware of than the slippery evasive reactions which had previously dominated her functioning. The dream was a kind of parable about dealing with evil. Verena Crick has drawn my attention to the similarity of Ariadne's dream to the theme of Mozart's opera The Magic Flute, in which, by the playing of a magic flute, the hero and heroine go safely through the dangers which beset them. Indeed, the coming into being of the intangible 'rhythm of safety' from tangible, sensuous, physical interactions between mother and baby is a kind of magic. Such a transformation is beyond our rational understanding. It is an everyday miracle. As Ariadne emerged from the constricted enclosure of her

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autism she became aware of her vulnerability and her fears of being assailed by evil. Let us now study the possible origins of Ariadne's sense of evil, which she became able to face when she got in touch with her 'rhythm of safety'.

Ariadne's sense of evil Work with autistic children has alerted me to the fact that one of the earliest differentiations is between 'clean' and 'dirty'. This differentiation would seem to come from the inbuilt hygienic dispositions which human beings share with the other animals. Instead of the normal differentiations, autistic children and obsessional patients such as Ariadne have developed rigid splits between 'clean' and 'dirty' - as also between other sensuous conditions such as 'full' and 'empty', 'wet' and 'dry', 'hard' and 'soft', 'light' and 'dark', 'strong' and 'weak', etc. They are afraid that if they experience the opposing contrary alongside the opposite state, one will destroy the other in a total way. For example, 'dryness' will totally dry up 'wetness'; 'hardness' will totally destroy 'softness'; 'darkness' will totally extinguish 'light'; 'weakness' will totally weaken 'strength'; and so on. A dictionary definition of the word 'rhythm' goes as follows: 'movement or pattern with regulated succession of strong and weak elements, opposite or different conditions'. It would seem that a regulated rhythm - that is, a shared rhythm which is outside the bounds of exclusively 'me'-centred restrictive practices - provides the possibility for contraries to be experienced safely together, for they can modify and transform each other. A creative intercourse is born. Having developed this rhythm of safety, Ariadne could now become aware of what she felt to be 'evil', because she no longer feared that it would totally destroy what she felt to be superlatively 'good'. Prior to this, her autistic practices had enabled her to feel 'good' by covering up what she felt to be the evil part of herself. Such patients often feel that they are whited sepulchres; in an attempt to get away

276 AUTISTIC BARRIERS IN NEUROTIC PATIENTS from feeling a sham, they react by naive, ill-judged, obsessional attempts at 'total honesty', which leads them into trouble with the people around them. Let us now study the origins of what is felt to be so superlatively good. In terms of inbuilt hygienic dispositions cleanliness is felt to be 'good', and this notion is embodied in the homely maxim, 'Cleanliness is next to godliness.' However, for patients such as Ariadne, 'dirtiness' became associated with unmitigated 'evil', and 'cleanliness' became associated with absolute purity. Although Ariadne had a great deal of charm, she was also a goody-goody and a prig. Her holier-than-thou attitude caused her friends to call her Miss Perfect. This notion of herself as being pure and perfect had been achieved by dissociating herself from the dirty, smelly, unacceptable'parts of herself which became 'not-me'. Thus, the amphitheatre of the outside world into which Ariadne feels that she is 'born' (both physically and psychologically) from the constriction of her autistic, 'me'-centred existence is a 'not-me' situation which has become imbued with the 'evil' which was 'not-me'. She had felt that she had been born into a world that was hostile to her 'going-on-being'. This had been made even more 'evil' by her own 'not-me' projections. Also, anything which comes from inside the body is felt to be contaminating, contaminated and dirty. So, being born from inside a mother made her dirty. Such patients make a rigid split between the inside and the outside of the body. They feel that their inside is turgid with the stink and filth of their unaccepted and unacceptable erotic excitements, rages, panics and griefs, all of which are experienced in a sensation way as irritating, dangerous body stuff which will be there forever. This is partly because what is inside cannot be seen and is, therefore, uncontrollable and dangerous. Thus, they live an artificial sort of life. They are an empty fake- a hollow sham. They live solely in terms of outside appearances and body surfaces in order to avoid the inner, unknowable darkness about which they are in despair.

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I talked with Ariadne about this in relation to the explosive shit of her tantrums, which were provoked by the frustration and terror of bodily discontinuity from the elemental being with whom she had struggled to feel eternally continuous. This shit was felt to be evil and obnoxious and offended her prudery about bodily processes. I suggested that her reaction was to see the dirty evil of the panic and rage of her tantrums in other people. Following this interpretation, Ariadne had a'flash of inspiration about the delusional jealousy which had plagued her for many years, and about which I had not been able to give her fundamental insight. She said, 'I've just thought that perhaps I do the same with my ecstasy. I can't bear it so I see other people enjoying it and then I'm jealous of them.' (This piece of insight was typical of the reflective interplay which characterized the session. ) But why had Ariadne been driven to such desperate extremes of splitting between the 'me' and the 'not-me'?

Splitting between the 'me' and the 'not-me' Autistic children have shown me that at elemental levels the rage, panic and grief of their infantile tantrums about frustrations, and their infantile ecstasy about satisfactions, were associated with bodily discharges. (You will remember that Daisy talked about 'discharging' 'savage and sad thoughts' and 'blissful thoughts'.) Such discharges are not acceptable to a depressed or obsessional mother who feels them to be obnoxious and unclean. Thus, they were not acceptable to the developing sense of 'me-ness' of the baby, for whom parental approval is important. This means that they are experienced as 'not-me'. The passive baby often becomes the 'unusually good baby' described by so many mothers of autistic children. As several writers have found, those autistic children who have an early history of tantrums (or fits without organic cause) usually have a more favourable prognosis than those with the 'unusually good baby' type of early history. This splitting also operates in another sphere of such

278 AUTISTIC BARRIERS IN NEUROTIC PATIENTS patients' functioning. Purity (cleanliness) becomes associated with the intellect and, because primitive emotions are associated with bodily discharges, the emotions become associated with dirtiness and are experienced as 'evil'. The scrupulously 'clean' intellect becomes overvalued at the expense of the 'dirty' emotions. As Dr Sydney Klein has said: 'The sooner the analyst realizes the existence of the hidden part of the patient,' by which he means the autistic part, 'the less the danger of the analysis becoming an endless intellectual dialogue ...' (Klein, S., 1980). Becoming aware of the hidden autistic part of such patients enables us to understand their deeply rooted fear of emotion, and also helps us to avoid becoming trapped by their arid intellectualism. Let us now study their fear of emotion and other intangibles. The autistic fear of intangibles For autistic children, feeling safe is dependent upon the delusion of feeling in absolute control of a mother's body which is felt to be a part of their body. The manipulation of autistic objects supports this delusion. These are not symbols of the mother's body; they are felt to be actual tangible bits of the mother's body experienced as part of their body which can be controlled at will. (In Hanna Segal's (1957) terms they are 'symbolic equations'.) The intellect can be used in a formal way in the service of this control and manipulation. It can narrow things down to what the child feels they should be, rather than helping him to see what they are. But emotions are a very different kettle of fish. They cannot be controlled and manipulated as tangible physical objects. T o autistic children, however, only what can be controlled and manipulated in a tangible way seems real and safe. Thus, emotional states either feel unreal or are felt to be bodily substances which are exceedingly evil and dangerous. If we talk to these children about emotions, they either do not know what we are talking about, or they turn away because it feels dangerous and unsafe. They may even feel that we are pelting them with dangerous

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bodily substances. The reassuring, enriching, intangible, safemaking aspects of emot.ionsare not available to them. It is the same with the reassuring, intangible processes of growth and healing. These cannot be seen, touched and manipulated and so they cannot believe in them. Such children feel that they can make themselves grow by sticking extra bits on to their bodies. This is imitation of a quite concrete kind. Since they also feel that these bits are plucked from other bodies who will want to retrieve them, these reactions bring terror in their wake. Because they are so afraid of letting things happen to them over which they have no control, the reassurance that growth takes place naturally, without their having to do anything about it, is not available to them. Similarly, autistic children have no reassuring awareness that they have inherent healing processes which will collaborate with therapeutic interventions. The whole of their efforts are directed towards 'covering' or 'blanketing' (to use Daisy's terms) the many holes and wounds which seem to afflict them. Thus, such children live almost wholly in terms of manipulative, body-centred evasions and artificial fabrications associated with sensuous experiences on body surfaces. They derive no sense of safety from the natural, spontaneous processes which go on unseen and uncontrolled by them. As well as being cut off from the reassuring processes of growth and healing, these children are also cut off from the reassuring intangibles of fantasies, imaginations, memories and reflective thought. Such children's potentialities for these activities are relatively untapped and unused. Thus working with autistic children we come upon unrealized potentialities. As Ariadne's autistic constriction became relieved, she became aware of another reassuring natural potentiality. This was her biological reproductive capacity. Realizing this assuaged her distress about not being eternal and immortal. She helped me to be aware of this in the following way. She had been to see one of the productions of a fringe theatre group. The production, which was called Vulture Culture, made a great

280 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S impression upon her. It was about the turtles which come up from the water on to the seashore to lay their eggs, which are immediately vandalized by humans. She realized that in walking through the evil amphitheatre she had been protecting her 'eggs' which were threatened with being vandalized. As well as her biological potentiality to have offspring which would carry her seed from generation to generation, and so help her to achieve a kind of immortality, Ariadne realized that these 'eggs' were also her creative capacities which had been 'vandalized' by her autistic predations. Until we had worked this over, she could not leave me. But we could not work this over until her autism had been modified, and she had developed more authentic means of feeling safe by realizing that she was part of a creative process which would go on after her mother's body and her own body were no more. T o extend Marion Milner's saying (Milner, 1969), not only is the analyst 'the servant of a process', but so is the patient. Ariadne was becoming able to be lived by her life, and so she developed a 'rhythm of safety', the capacity for which she had previously been unaware of. It was beyond her manual and intellectual control. Like growth and healing, this potentiality was a 'given'. It occurred without her arranging that it should happen. It gave her a much greater sense of safety than her own puny manoeuvres. The possibility for her awareness of this creative capacity was the result of a significant breakthrough in our work together, which came about in the following way.

The significant breakthrough About six months before Ariadne had the dreams which stimulated her important forward movements, and when she was in a state of despair about ever being ready to finish coming to see me, I began to wonder whether she was using parts of her body as autistic objects, as the autistic children did. So I asked her quite directly whether she sucked or bit the inside of her cheeks, or sucked and bit her tongue, or wriggled her bottom to feel the faeces in her anus. She willingly told me that from being

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a little girl up to the present day, she had bitten and sucked the insides of her cheeks. Such autistic manoeuvres are hidden and secret. I had never seen Ariadne using them, and she would never have thought to tell me about them unless I had asked her directly. 1 dealt with them in a similarly direct way by saying that it was important that she should try to stop doing these things. I explained to her that I thought that she did them in order to delude herself that she had a fleshly bit of an everlasting mother always with her, so that she could feel that her body was continuous with that of an eternal fleshly being who completely ensured both her safety and her existence. This was an important turning point in Ariadne's treatment and cleared the way for the dreams which stimulated her awareness of the 'rhythm of safety'. This, at depth, arose from an acceptance of the rhythm of life with its joys and with its sorrows. (I remember an autistic child for whom this was exemplified by the inevitability of the changes of the seasons as he came through the country lanes to the converted pony-shed which 1 used as a therapy room.) Ariadne has since told me that my disciplining firmness in telling her to stop sucking and biting her cheeks made her feel that I really cared about whether she grew up in the right way. She will now sometimes tell me that in moments of stress she has found herself sucking her cheeks, and has immediately stopped doing it. Benign authority was becoming part of her experience of me. After discovering Ariadne's use of part of her body as an autistic object, I concentrated on showing her how these 'techniques' (as she came to call them) had prevented her from coming to terms with the inevitable facts of bodily separateness. She began to realize that her manibulative techniques had led her to delude herself that absences and partings could always be avoided. Thus, mental activities which bridge the gap of separateness - such as fantasies, imaginations, thoughts, memories and metaphors - were very undeveloped. No wonder that, as a child, she had been referred to me for 'learning

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difficulties'. Sadly, at that time, I did not understand her autistic handicaps and so could not help her as fundamentally as I have been able to do in the second phase of her analysis. I have come to realize that the autistic part of the personality is the part that avoids comlng into the analysis. It is the intractable part of infantile experience which could not be 'digested' and has been hidden away. As well as being locked away in autistic objects and autistic shapes, it can also be locked away in idiosyncratic movements and tics. Lam reminded here of James Robertson's film of Laura, the two-year-old, very controlled little girl who was separated from her mother by being hospitalized. She shut away this 'unthinkable' experience by the tic of brushing her hand across her face, as if wiping away the tears she could not shed. On a more sophisticated level this hidden autistic part can be seen in some children's excessive preoccupation with tongue-twisters, conundrums and riddles. This was also characteristic of the ancient Celts described by Daphne Nash at the end of Chapter 8. It is the twisted part of the patient which feels unknown and unknowing because bodily separation from the mother has been experienced as an obliterating catastrophe. Autism is anti-life, but 'anti-life' is not synonymous with death. Dying is an inevitable part of the life process. Autistic techniques are reactions to avoid becoming conscious of the 'black hole' of separation, of ,partings, of endings, and ultimately of death. In so doing, they cut the individual off from life. It is only as we become aware of the fact of death that we fully value life. In the second phase of treatment Ariadne began to realize that, for her, endings and partings were not merely experienced as rejections (as they would be by more normal neurotic patients), they were experienced as a violent tearing apart of her body from that of a being with whom she had felt continuous, and who had unrealistically seemed to guarantee the continuity of her bodily existence. The wounds from this violent ripping apart needed to be healed before she could bear to end her bodily contact with me. As De Astis and

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Giannotti (1980) have shown, the caesura of birth is healed for both mother and baby, in normal development, by their mutual intereactions with each other. The autism had been a kind of plaster cast which had immobilized this wounded part of her. As she gave up her autistic practices, Ariadne became aware of her own intrinsic forces of healing, and also of the firm but tender care by which she was surrounded. In short, she became aware of 'love', not of the sentimental 'heart-throb' kind but as an adaptive adjustment to her needs which arose from reflective thought, which also became possible for her. She began to be able to experience the agony and the ecstasy of being a fallible, finite human being who could die. Instead of evading them, she began to face the conflicts, difficulties and pains of ordinary living. She found that there were joys as well as sorrows and that, as she experienced uprightness in herself and in me, she became able to bear both. Her fear of madness associated with dirt and disorder, against which the autism had been a protection, was also alleviated. She no longer feared that the discharge of uncouth feelings would pollute the absolute purity of her body and cloud the absolute clarity of her mind. These extreme splits were modified as she became aware of a shared integrative rhythm of adaptive human reciprocity which embraced both the acceptable 'me' and the rejected 'not-me'. For this development to become possible, Ariadne had needed to be sternly encouraged to give up her massive evasions of reality. Quite concretely, she had put her own narrow construction upon the outside world. Her autistic contrivances had made her stilted, narrow-minded and rigidly conforming, to the point of passivity and timidity. But underneath this shying away, she had felt very special. All this had protected her from the inevitable pains of being a human being, but had also shut her away from being aware of, and of becoming capable of, love in its functions of empathy, interest, attention, consideration, compassion, care and understanding. The un-

284 A U T I S T I C BARRIERS I N N E U R O T I C PATIENTS couth, brutal aspects of her nature had remained unmodified and had shocked her when she had encountered them. Conclusion Those fortunate individuals who, in early infancy, have been able to enjoy and internalize emotional experiences of a rhythmical, adaptive interaction of the mouth differentiated from the breast are receptive to later experiences such as human sexual love, and aesthetic and religious experiences. For such people, these are not used in shallow and stereotyped ways as autistic evasions of the inevitable realities of human existence. They are deeply felt experiences which build upon, enrich and revitalize that intrapsychic creation which Ariadne so aptly called 'the rhythm of safety'. This intangible creation is primitive but complex. It is what the autistic child should have achieved but has not. Experiences at the breast - or bottle experienced in terms of an inbuilt expectation of the breast - provide a foretaste of the inevitable life situations to come. In relatively normal development these are met in the protected situation of the reverie of maternal preoccupation (Bion, 1962a; Winnicott, 1958). If this is disturbed, the infant is left in the grip of atavistic, savage terrors which played a part in human evolution but which are now vestigial. In normal development this savagery is humanized and civilized by that transforming empathic communion between mother and baby which is the earliest form of communication. Early, basic, bedrock processes set the pattern for later experiences. If, for any reason, evasion becomes the predominating reaction, evasion becomes the way in which all later difficulties are dealt with. It is a long and arduous task for both therapist and patient to bring about changes in these basic structures. But the effort is worthwhile, for these patients give us new ways of catching the meaning of those wordless intangibles which are of such deep significance in human living. They also free us from the jargon and cliches of words that have

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been worn smooth by use. They stimulate us to evolve more feelingful ways of expressing things. As a result, the mental and spiritual life of both analyst and patient is strengthened. T h e reflective interactions which developed between Ariadne and myself have meant that, for both of us, immortality has come to be seen in less crude terms than mere bodily survival. Thus, this chapter has been written as a tribute to Ariadne, as also those recovered autistic children who, like her, have had the courage to face those mortal terrors which these patients experience with such hypersensitized intensity.

CHAPTER SIXTEEN

Psychotherapy with psychogenic autistic states A warmth within the breast would melt

The freezing reason'ecolder part, And like a man in wrath the heart Stood up and answer'd 'I have felt.' Tennyson, In Memoriam,CxxIII

'arious aspects of the psychotherapeutic process with psychogenic autism have been referred to as the themes of this book have been presented. In this final chapter, it will be useful to gather together the insights into psychogenic autism which have been developed as the book has progressed. These will aid us in our attempt to develop psychoanalytic psychotherapy which is closely in touch with the nature of psychogenic autism. Psychoanalysis was originally based on the study of patients who had developed the basic possibilities for human relationships. Thus, in the early stages, our work with nonrelationship autistic states will have certain differences from that with the more usual relationship-oriented ones. It is a lack in England that there is not a research and treatment unit devoted to studying the psychotherapeutic possibilities for this disorder. This may be because in the 1950s psychotherapists

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and psychoanalysts made undue claims for the benefits of a type of psychotherapy which was not closely based on a detailed understanding of the disorder, and they blamed the mothers. Such a simplistic approach was found to fail and, naturally, some mental health workers now completely reject psychotherapy for autistic children. They have come to view all types of autism as untreatable conditions, and autism as being restricted to autistic children. T o say, as I am saying, that if we begin to understand better the nature of that autism which seems to be psychogenic in origin, sonre autistic children can be helped to normal functioning, will seem to such colleagues to be unlikely, un-understandable 2nd even irresponsible. Also, to say in addition that such work has thrown light on certain neurotic disorders which have a hidden capsule of psychogenic autism may seem to them to be preposterous. For my part I am aware that to write about such work always makes it sound easier and simpler than it is. In actual fact, it is very difficult. There is much that we do not understand. Nor is it work that all psychoanalytically based psychotherapists find compatible with their personality. Finally, we come up against the fact that our knowledge about the psychic situation of a patient in a state of autistic encapsulation is, to some extent, a matter of hindsight. It is only as they become freed from its immobilizing influence that they can tell us about what it was like. Some analysts have been in touch with the states being discussed in this chapter without specifically relating them to autism. For example, Enid Balint, in 'On being empty of oneself' (1963), describes a neurotic adult patient whom we would now recognize as having autistic features, and whose psychic development was freed and facilitated by work with Mrs Balint. However, in clinical work with autistic children we see autistic phenomena manifested in a simple context, and this helps us to evolve a basic scheme for the psychotherapeutic treatment of autistic conditions. There seem to be three main overlapping phases in the treatment of psychogenic autism.

288 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S 1

2 3

Modifying the autistic barriers so that relationships with people can be set in train. Healing the damaged psyche. (Psychotherapy can begin.) Psychoanalysis as it is ordinarily practised. (This need not be discussed as it is well known.)

Phase I Modifying the autistic bameus The autistic encapsulation of autistic objects and autistic shapes When we have become alerted to them, the use such patients make of autistic objects and autistic shapes is very obvious, and examples of it have been given throughout the book. Later, as the patients emerge from the paralysing effects of the autipm, they tell us about their illusion of being damaged, and we begin to understand the usefulness of these practices in seeming to protect them from the existential dreads which have been discussed in other chapters. As such, they perform very important functions and need to be respected. But they prevent healing influences from playing upon the patients, and thus they need to be deterred from using them. It is only by understanding their function that we can help them to find more realistic and effective means of protection. These practices mean that autistic children's capacities for empathy and imagination have not developed. Thus it is important that the therapist should have these qualities in good measure, so that, as it were, they 'rub off' on to the autistic child. All that has been said so far in relation to autistic children also applies to adult patients who we suspect have a capsule of autism which is impeding psychoanalytic work with them. D r Nini Ettlinger had a woman patient whose costume jewellery was used as autistic objects (personal communication). Mrs Enid Balint has very recently described Mr Smith, an adult patient whom she recognized as having marked autistic features. This patient quite literally 'cushioned' himself against the impingement of disturbing experiences by using the softness of a cushion on the analytic couch to generate autistic shapes, and the hard corner of the cushion as an autistic object

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(Balint, E., 1986). It is such behaviour on the part of neurotic adult patients that findings from work with psychogenic autistic children can help us to understand. When neurotic patients are in the grip of their hidden capsule of autism, they seem hard and impenetrable. They talk as if they know it all, with little respect for the analyst's experience and interpretation. They do not seem able to take anything in. In this state, they are adept at playing upon their analyst's weaknesses and human flaws. They do this in the nicest possible way, so that it is hard to detect. It is only when the therapist realizes that his or her authority has been undermined, that (s)he realizes what has been going on. Children do this more obviously than adult patients, by trying to push the therapist out of his or her chair, or by sliding into it if, for any reason, it is unoccupied. In this state, these patients become 'know-alls' who try to teach us our job, and who are very affronted when we will not conduct the analysis in the way they think it should be done. They do all this so charmingly that we are liable to become as anaesthetized by it as they are by their use of autistic shapes. Autistic patients have hoodwinked themselves and, if we are not careful, they will hoodwink us also. An analysis conducted on this basis can go on forever, with no hope of a satisfactory termination. From infancy onwards, such patients have taken 'the bit between their teeth', and in an autistic state they are impervious to outside influences which could modify their bland complacency. When this brittle self-sufficiency can no longer be maintained it is devastating for them. They experience a breakdown. This can be of varying degrees of severity. One patient described it to me by saying that 'the glaze is cracking'. She went through a difficult time but emerged, with psychotherapeutic help, to an enriched mode of functioning. This patient has done well, but before doing so, she had to go through Phase 2, with many retreats into her autistic shell. Gradually, these have become a reculer pour mieux sauter.

290 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S Used in this flexible way, a retreat can become a useful resting time until the individual is strong enough to take the 'better jump'. The trouble with rigid, inflexible, more permanent retreats from everyday life is that they trap the individual, so that perception is restricted and untransformed sensations become predominant. As always in autism, an innate disposition which could have been useful has become over-used in a way which is deleterious to ongoing psychic development. In such autistic states there is a taboo on tenderness. However, when the autistic capsule begins to crack open, we see the hypersensitivity against which it has been a protection. This warns us that we need to be careful but firm in modifying the autistic protections. Also, as they encounter the part of their personality which has been a hollow sham, such patients experience great waves of despair. Modifying the autistic protections is a sensitive but necessary task.

Modgying the autistic protections These artificial practices have buried the natural human responses of such patients. In autistic states, patients feel that they are inanimate things surrounded by threatening inanimate things. T o get away from these threats they bury themselves in autistic practices. Ariadne, the interesting neurotic adult patient we met in the previous chapter, once said to me, 'y' know, I feel I came to you buried with a whole heap of rubbish and that you found the flame of sanity underneath it, and fanned it into life.' Dr Bion was very clear that this was an important function of the analyst. He wrote: 'I have no doubt that the analyst should always insist, by the way in which he conducts the case, that he is addressing himself to a sane person and is entitled to expect some sane reception' (Bion, 1977). It is by addressing this sane human part, and by behaving sanely and humanly oneself, that the therapist is provided with one way of modifying the autistic encapsulation. Getting through the heap of nonsense engendered by the use

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of autistic objects and autistic shapes has an analogy with getting through the heap of rubble which buried the newborn babies in the Mexican earthquake last year. Paediatricians tell us that the babies survived for a longer time than older people because the newborn infant has an innate facility for slowing down physiological processes such as breathing and heartbeat, and so could survive in this state of diminished response for a longer time than might be expected. The diminished physiological responsiveness can seem to have an analogy with the diminished psychic responsiveness of autistic children; and the tunnelling through the rubble can seem to be an apt description for the work that the therapist has to do in the first phase of treatment. But, like all analogies, it must not be pushed too far. The babies in the earthquake survived for up to a fortnight. We do not know that there is such a time-limit for psychic survival. For some people, psychic resuscitation seems to be possible even into old age, as witness the elderly patient treated by Hanna Segal(1958). As we talk to the human, sane part of the patients about their use of autistic objects and autistic shapes, we offer them something better by our behaviour and our words - we offer them a firm but sympathetic understanding of their difficulties. T o do this, we have to empathize with them in their distresses. But empathizing with patients in autistic states does not mean losing our own sanity. Rather it means finding points of contact with them. Previous chapters have sought to describe some of the battery of inborn responses which are shared by all human beings. We have seen that, as the result of their restriction of outside experiences, autistic children operate mostly in terms of these inbuilt predispositions; and since these are relatively unmodified by outside experiences, the children react in an exaggerated and hypersensitized way. In a less exaggerated form, we share these inborn dispositions and so, to some extent, we can identify with the children. The book has sought to help the reader to do this. It has hinted that all of us are likely to have a bit of autism in our

292 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S make-up. Autistic children are not a different species from ourselves. There are many points where we can make contact with them, and, in so doing, we talk directly to them and with feeling, so that they feel understood. This gradually encourages them to lower the barriers of their more extreme autistic reactions. As we do this, we begin to realize that psychogenic autism is a fundamental disorder of perception. We come to see that the shape-making dispositions of the human mind have gone along a deviant and futile path. Elementary shapes are constellations of sensation. In normal development, these sensation shapes become associated with actual objects in the external world, at first probably with the breast. This trans-formation of sensations into concepts and percepts, through the shapemaking dispositions of the human mind becoming associated with actual objects, is impeded in autistic children because of their lack of trans-actions with the outside world. Instead, actual objects are used to generate autistic objects and autistic shapes which, being self-generated, are like mirages in the desert. They have no existence in actuality. Patients in autistic states are trapped in an unshareable world of self-generated tactile sensations. Only things which can be touched and manipulated seem real. Because they cannot be seen, touched or handled, psychic experiences are outside the scope of these children. Thus memories, thoughts, fantasies, imaginations and play are not within the range of their possibilities. Symbolic representational activities are not possible for them. It was a great step forward when John, in Chapter 4, represented the breast by placing two coloured pencils in the form of a cross, saying 'Breast' as he did so. We have also seen that an important reason for their shutting out the outside world has been that, as particularly sensitive children, for various reasons, they have felt that their overtures were rebuffed by the suckling mother of their infancy. This has provoked an agonized awareness of their separateness from the mother who is their first representative of the outside world.

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The reaction to this has been to avoid any further repetitions of such awareness. This seems to go into their avoidance of looking directly at people. Patients in autistic states live mostly in terms of peripheral awareness, listening to tones of voice, for example, rather than to what is being said to them. In adult neurotic patients this autistic part reacts in a devious way and avoids straightforward, direct contacts with people. Everything is approached in a roundabout way - one patient having to take a very roundabout route to his analyst's consulting-room when there was a much more direct route which would have got him there much more quickly. Ariadne used to tell me stories in which she went off at many tangents before getting to the point of what she was telling me. I think it is for this reason that these patients appreciate straightforward directness in their analyst. With small children, it is no good pulling their faces round to make them look at people until they have the motivation to do this. They do not have the motivation to do this until their fears of looking people in the eye have been to some extent worked over and understood. For example, John said that he was afraid of the 'black hole' in the middle of people's eyes. Other children feel that eyes can do very dangerous things. For them, 'cutting looks', 'piercing looks' or 'killing looks' are not just figures of speech; they really feel that looks can kill, and so they avoid looking. For them, as we have seen, the outside world is full of unmitigated savage terrors, and so it has been shut out. They have wrapped themselves in their own sensations. These cannot be transformed into perceptions until their terrors are worked through with an understanding and receptive person. On the other hand, this does not mean being soft with such patients. I have found that we need to be more firm and active than is usual in most psychoanalytically based psychotherapy. As a drug addict once said, 'Parents need to be stern in their love.' With patients who have become addicted to autism the therapist has to behave iri this way also. For example, in my work with Ariadne, I firmly directed her to try to stop biting and sucking the'iinsides of her cheeks. I associated this with an

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interpretation as to why she should stop 'conning' herself that she had a fleshly 'mother' always with her, at her beck and call at any time, which ensured her continuous existence forever. Of course, active intervention should always be associated with an explanation as to why the deleterious behaviour should be giver1 up. Such direction only works when the therapeutic alliance is firmly established. For many years, Ariadne had been in the second phase of treatment, but hidden bits of autism still clung around her like bits of eggshell. Emergence from autism is not a clearcut, once-and-for-all procedure. When I presented the paper about Ariadne's treatment in various psychoanalytic institutes, there was always a great deal of discussion about this piece of directive behaviour on my part. Such behaviour on the part of the therapist runs counter to the usual psychoanalytic practice, which abjures active intervention in the patient's life. But non-symbolic autistic states are different from any others that we see. Autistic behaviour is on an almost reflex psychochemical level. Locked in a primal crow-black sulk, such patients have gone along a futile and self-destructive route of non-relationships. Something incisive has to be done to help them back to relate to the 'breast' properly - to bring them back to common sense. My telling Ariadne to stop biting the insides of her cheeks was similar to a caring parent who acts to prevent her impulsive toddler from rushing across a busy traffic road. Following the giving up of such idiosyncracies, there is usually some acting out of the feelings which had been locked away in the autistic behaviour. The therapist needs to be alert to these in order to bring them under therapeutic control. The patient in this state is relieved when the analyst comes down incisively on the side of living. In my view, we should always do this with patients who have a strong 'pull back to the inanimate', as Freud expressed it, since, for these patients, suicide is the final bid to escape from what seem to them to be unthinkable, irremediable difficulties. As I see it, in everything that we do, we need to come down on the side of life and hope.

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It is knowing how and when to give stern guidance which is part of the art of psychotherapy. Paternal authority Another lesson I have learned from work with autistic states is the importance of not allowing the analyst's authority to be undermined. As we have seen in previous chapters, these patients have often had a mother whose confidence was being undermined in various ways, and a father whose presence, for various reasons, was insufficiently felt. T h e children have had to cope with more than their undeveloped psychic resources could deal with. In a naive state, they have felt that they had to be strong and invulnerable. They have also been left too much to their own devices, and have not had sufficient support and guidance from experienced and confident authority. As John's material in Chapter 4 indicated, he had undermined and exploded away the 'Daddy' element in his nurturing. This had been associated with what John called the 'button', that is, with 'teat-tongue' experiences at the breast. Clinical work compellingly indicates that the 'teat-tongue' combination becomes associated with the hardness of the 'Daddy', and with authority which regulates the children's impulsivity. This authority does not allow them to have all their own way, and presents them with the reality of their dependence on others. Autistic children have been allowed to feel that they can make up the world in their own terms, and that people are as clay in their hands. Thus, they have destroyed their connection with the 'breast', that first introduction to the outside world, with all the adjustment and adaptation which such connection implies. In impotent rage, they have exploded away the thing they have to share and which is not for them alone. They never experience being an ordinary member of an ordinary family. Like John who said, 'Make a bigger breast,' they are always seeking that elusive 'extra bit' which will make them extra-ordinary. They have rejected the father's disciplining authority which sets limits. In a paper concerned with the 'missing paternal dimension',

296 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S Phil Mollon brings a vivid piece of clinical material, which demonstrates the disaster that ensues if the paternal authority is not sufficiently recognized. This material concerned a patient, Miss D, who, in the terms of the chapters in this book, obviously had a very operative autistic capsule. Her autistic encapsulation began to crack when she made use of the couch for the first time. Mollon writes as follows: As Miss D made use of the couch she became more overtly dependent and vulnerable, and began to talk of feeling in a frantic, hungry and disorganized state, particularly emphasizing a sense of having no centre. She pointed to a picture in my room, an abstract painting which she considered very fragmented; she said 'I feel like that painting no core - it looks like it was painted by someone who wasn't all there.' She then laughed and said, 'You didn't paint it, did you?' I told her I thought she felt like a frantic, inwardly falling-apart baby, confronted by a mother therapist who seemed not quite all there - and that she was longing for a hard nipple, a core around which she could organize and orient herself. This interpretation seemed to calm her considerably. I quote it here because I think the core she sought could be a most basic and .concrete metaphor for the paternal function required to provide boundary and organization. (Mollon, 1985)

W.B. Yeats has described the demoralizing effects of this lack of a central core to the personality. I n 'The Second Coming' (1962, p.99) he writes: Things fall apart; the centre cannot hold; Mere anarchy is loosed upon the world, The blood-dimmed tide is loosed . .. John's material shows us that the 'Daddy button' is the central core that has been lost. Ariadne found this core when she estabished her 'rhythm of safety'. For this establishment to occur, these patients had to be able to mourn for the tangible

THERAPY I N PSYCHOGENIC AUTISTIC STATES 297 sensuously exciting object which was felt to be a part of their body and which had been lost. This mourning established it as a creative mental conception which held them together, and connected them with others. For this to occur, they have to bear the disillusionment that things come to an end, and that they are ordinary human beings who can come to an end also.

The capacity to mourn John's material demonstrated convincingly that it was only when primitive processes of mourning were worked over that the 'button' became a psychic conception which set creative cognitive and emotional processes in train. The clinical material of Ariadne showed us that, in adults, this can be a long and protracted process. Ample time is needed if the mourning is to be satisfactorily integrated into the personality. It is hard for such patients to give up the unrealistic notion of living forever through the illusion of continuous, fleshly connection with an eternal 'being' who is for them alone. It was only when Ariadne could give up this autistic notion that. the 'rhythm of safety' began to be established. Prior to this, her secret autistic practices had prevented this development. She herself said that she had experienced my stern injunction to give' them up as a sign that I really cared about her. It cleared the way for the dreams which enabled her toface her terrors instead of avoiding them, and to begin to be ready to finish coming to see me. T o be able to do this, she had to become able to do without my physical presence so that I became a psychic resource in her mind. That she is getting ready to finish was shown by a recent dialogue with me when there seemed likely to be a seven-week gap in what had now become her monthly visits to see me. I offered her a three-week or a seven-week gap, since the day of her monthly visit was not available. After some thought, she looked up with an amused smile and said, 'Shall we be daring and try seven weeks?' For such a cautious and timid person, this was a great achievement. But a great deal of psychic work had had to take place before this was possible for her.

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Psychic work Work with psychogenic autistic children and neurotic patients with a capsule of psychogenic autism has made me echo Murray Jackson's (1985) conviction that 'Some psychoses ... demonstrate that the ego does not always simply fall apart as a result of biological deficiency and psychosocial stress, but is destroyed and fragmented by forces within the personality that prefer oblivion to pain, or confusion to depression ...' (see also Ogden, 1980; Rosenfeld, H., 1971). It is the study of the psyche which informs the type of psychotherapy being described here. These patients need time and freedom from undue pressure. We need to be able to wait so that they can learn to wait. Yet, at the appropriate time, we need to be able to sense that they are ready to bear the pressure of active intervention to help them to leave their aberrant ways, and to bravely take the main highway which they share with other ordinary earth-based human beings. T o do this, they have to work over their mourning for a sensuously beautiful object which cannot be grappled to them as a physical part of their body. As they do this their lives become irradiated by an aesthetic vision such as Dave experienced at the crags. This is not a rarefied, esoteric, aesthetic vision which is as fragile as is the autistic child's fascination with his self-engendered iridescent bubble of spit. It is a robust, interactive enjoyment of the beauty of life which does not ignore the reality of evil and ugliness. For this to be possible terrors have to be faced; and illusory ones are harder to face than actual ones. Through such courage, psychic life becomes freed from an incubus which can virtually destroy it. The devastating effects of psychogenic autism As well as arresting the development of emotional and intellectual life, psychogenic autism has prevented the development of a moral sense. This is to be expected, since Dr John Bowlby's study of delinquency has shown us that geographical separation from the mother in early infancy is liable to result in an 'affectionless character' (B.owlby, 1973). Autistic children have experienced

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psychological separation from their mother. Their resulting psychopathic tendency was brought home to me very forcibly on reading a paper by the French psychoanalyst Dr Janine Chasseguet-Smirgel, who was writing about perversion. In the paper she used perversion in the ordinary, everyday sense and did not restrict it to sexual deviation, as is the case in most psychoanalytic writings. As an example par excellence of perversion in this more general sense, Smirgel analyses the character and writings of the Marquis de Sade (ChasseguetSmirgel, 1983). Although she does not use the word autism, all that she says about perversion applies to the spurious and devious behaviour characteristic of autism. For example, she describes the anal preoccupations, the avoidance of feelings of tenderness, vulnerability and helplessness, the pseudo-independence, the undifferentiation and merging, the avoidance of differences and opposites, the non-recognition of the mother and of family ties. There is also reference to unmitigated savagery, for in Justine de Sade makes one of his characters say, 'The creature I am destroying is my mother.' Later he speaks of 'tearing apart the breast that suckled him' (1967, pp.209-10). As the autism is modified, such primitive savagery will be expressed by the patients we are discussing. In autistic children it has been hidden by their use of hard autistic objects and soft autistic shapes. The soft autistic shapes have replaced the maternal functions, and the hard autistic objects have replaced the paternal ones. In neurotic adults with a capsule of autism, psychopathic tendencies are often covered over by obsessional reaction formations which result in priggish behaviour and judgemental attitudes. With such patients - both autistic children and neurotic adults - this potentiality for cruelty is often turned against themselves in that they will cut and hurt themselves, bring their creative endeavours to an abortive halt, or, at worst, kill themselves. Such patients' potentiality for cruelty is often overlooked. In psychotherapy with them it is important not to collude with

300 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S their 'cover-up' of this part of their personality. It is vital that we should be aware of the unmitigated, atavistic savagery which has never been modified by loving interactions with the suckling mother. Autistic children have almost completely rejected the 'breast-mother', and neurotic patients with a capsule of autism have a part that has violently turned away from her. All possible healing overtures from her, tentative though these may have been, have been rebuffed, just as, in their early painful awareness of separation from her, they felt that they had been. There is a wayward, callous part of the personality. It is dangerous because it is often associated with great charm. An important part of the first phase of psychotherapy is to encourage such patients to relinquish their sidelong autistic practices so that they can have a straightforward relationship with 'life' and its vicissitudes (the 'breast' in infancy), and develop beliefs and a sense of purpose. In psychoanalytic therapy this occurs through the infantile transference. Through this medium, the patients respond to the therapist as the 'breast' of infancy, and are enabled to work over their feelings of sulky umbrage about its inadequacies in terms of their exacting expectations. These perfectionist expectations have become more exacting as the years have gone by, and the patients have brooded upon their disappointments. No therapist, however good, could possibly fulfil them, so they have ample opportunities to meet their disillusionment about human inadequacies and to come to terms with it. As we saw in Ariadne's reactions, the outside world, in terms of their perfectionist, purist expectations, seems polluted. They have shrunk away from this seeming contamination. T o help them to have a more robust approach to life and living is part of the psychotherapy. It is no good treating such patients as if they are precious bits of Dresden china. They often try to get us to do this, but we must not collude with it. They have many strengths which they have never discovered, and we must help them to discover them. This goes on in every phase of

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psychotherapy. Let us now return specifically to the first phase, during which we are trying to modify the autism. An awareness of the type of body image which such patients have in an autistic state is a help in doing this.

The autistic body image In this first phase of treatment we meet a patient who has 'jumped out of his skin' with fright, and who feels skinless and disembodied. T h e skin has been replaced by the 'armour' of his autistic practices which help him to feel protected from the terrors of falling, of dissolving, of spilling, of losing a sensuous object as a part of his body which ensures everlasting continuity. In Chapter 12 we met the neurotic adGlt patient who felt that this skinless part of her lived inside a walnut shell. At the beginning of his psychotherapy with Dr Maiello, Antonio, in Chapter 13, was floating around in a disembodied state. At first, these patients have to be enfolded with firm, confident, understanding care, so that they begin to feel that it is safe to give up their empty, armoured or disembodied state. In their autistic state such patients feel 'paper thin'. They do not differentiate between insides and outsides, and live in terms of surfaces and superficial appearances. They have no awareness of their own insides. As we saw with Peter, in Chapter 6, there was a gap where his stomach should have been. D r Sydney Klein, in writing about neurotic adult patients who manifest autistic phenomena, says that they have a 'thinness and flatness of feeling' (1980). Work with autistic children reveals that they live in a flat, two-dimensional world. For example, one autistic boy, very fascinated by a picture which hung on the consulting-room wall, would go up to it and turn it over to see what was behind the hills on the picture. Another child would draw the back of a house on the reverse side of the paper on which he had drawn the front elevation of the house. As Ted Hughes said in the verses from Crow which introduced Chapter 6, such patients feel that their 'body' is 'intermittent'. They do not feel that it has a middle part which

302 AUTISTIC BARRIERS IN NEUROTIC PATIENTS is a place where things can be stored and digested, and which would join the upper and lower parts of the body together, and make it three-dimensional. As we saw, autistic objects and autistic shapes are two-dimensional. It was the impression that they made on body surfaces which was attended to. They had no significance in terms of actual, three-dimensional objects in the outside world. T h e emergence of the geometrical shapes of the circle and the triangle ushered in three-dimensional awareness. These had both insides and outsides. They could contain something, and were different in this important respect from zigzags or rounded scribbles. When elemental sensation shapes become associated with shareable geometrical shapes which are 'containers', as also when they become associated with actual, three-dimensional objects in the outside world, percepts and concepts can begin to develop. This ushers in Phase 2 of the psychotherapeutic process.

Phase 2 Healing the damaged psyche The body image associated with this state As the autistic shell is cracked open by dawning awareness which shatters the autism, a helpless damaged creature is revealed who feels that a vital part is missing. U p to this point, this vulnerable creature has been protected by feeling wrapped up in his own bodily sensations. These have been a protection against the disorder and confusion of madness. As they emerge from autism we see such patients' fear of madness. Emergence into this second phase of increased perception brings an agonizing state of hothouse hypersensitivity in which they feel skinless. They also experience states of icy clarity. Associated with these, there is the sense of thawing out. Anne Bronte expressed this poignantly when she wrote: Oh dreadful is the check - intense the agony When the ear begins to hear, and the eye begins to see; When the pulse begins to throb, the brain to think again; T h e soul to feel the flesh, the flesh to feel the chain. 'On Becoming', Poents

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The autistic protections having cracked, the reaction is to feel wrapped up inside the body of the therapist (the mother in the infantile transference). This enfolding has been termed symbiosis by Margaret Mahler. It is a state in which projective identification, as described by Melanie Klein, is active. It was exemplified by Steve in Chapter 12 who, after one-and-a-half years of psychotherapy, drew a red oval containing two shapes, a smaller oval and a circle. Madame Cauquil, his psychotherapist, felt that these two containers within a large one indicated that Steve felt that he and his therapist were held within a shared ambience. Within this context of 'togetherness', Steve could begin to have a sense of identity, and could begin to think. In this state, each other's existence is felt to depend upon the actual physical presence of the other. Thus, partings are excessively painful and terrifying. Dr Bion has amplified Melanie Klein's concept of projective identification, and has shown us that it facilitates the development of thinking. The child projects a scream, a tantrum or some other piece of impulsive activity; the mother empathically identifies with it and understands it. She responds appropriately. Gradually, instead of using explosive projection, the child begins to be able to sustain tension and to delay action, which is the basis for thinking. But for this to become possible, the child's protests must not seem to go into an unattentive void, nor to rebound back at him from a seeming brick wall. The mother does not necessarily 'give in' to him, but she responds in some appropriate way. It has seemed to me that the processes of empathic interaction (projective identification) are important in the healing that takes place in Phase 2. The therapist is now felt to have an inside, and damaged patients feel that the damaged parts can be reposed within the therapist's 'stomach-mind', so that the attendant terrors can be 'stomached' for them until they can begin to 'stomach' them for themselves. In Phase 2, this empathic 'stomaching' is the psychotherapist's most important healing role. But it is important that we do not go on performing

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this service for the patient when he is well able to do it for himself. All our work has to be directed towards his becoming able to do this for himself by the development of healing psychic images, aesthetic images being very important in this. The fact that the damage is often illusory makes it very potent and difficult to deal with. In patients who have actual bodily damage, either at birth or later on, feelings about this actual damage can become confused with feelings about illusory damage. This makes it difficult for them to come to terms with either of these situations. Patience is needed on the part of both therapist and patient in working through and disentangling these threads. In Phase 2, although the patient is developing a sense of identity, this is by no means securely established. It is dependent on seeming to live inside the therapist's skin (as if it is a mother's skin). The aim is to help such patients to develop the sense of having an intact skin of their own. As we have seen from both Steve and Jean in Chapter 12, interruptions to the treatment can make them feel that there are gaps in the envelopment by the skin of the therapist-mother, and that they are leaking out of it. This can either stimulate them to develop a skin of their own, or it can drive them back into psychogenic autism which seems to callus them over with an artificial skin. Phase 2 is a confusing period because there is constant slipping back from a state of feeling human and alive into the inanimate empty fake of autism. In the interactive coexistence of Phase 2 in which healing becomes possible, there is dawning awareness of 'me' and 'not-me', but the 'not-me' can sometimes be so unbearable that it is'blacked out'. However, this 'blacking out' gradually comes to be countered by the use of the transitional object and transitional activities (Winnicott, 1958). This buffers the child against too painful experiences of the hard 'not-me'. We saw this in Sam's use of the piece of shawl in Chapter 9 which, when sucked, gave him the sensation of a beneficent circle. However, his thumb gave him the 'nasty' sensation of a triangle with sharp corners. This was the hard

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'not-me' which could not be moulded to be what he wanted and expected it to be. The therapist has to be firm in encouraging such patients to find the courage to 'stomach' the hard 'not-me' bit. When they start to 'kick up a fuss' about the hard 'not-me' which will not be controlled by them, but instead does unexpected things and so brings shocks, they are well on the road to recovery. All the unconscious phantasies described by Melanie Klein become operative in this phase. In unconscious phantasy, the inside of the mother's body is attacked and repaired. Also, the imagination is stirred by these unseeable inside places; as witness Dr Maiello's patient Antonio, in Chapter 13, who fantasied about the wonderful Maiello things he imagined were hidden away in the rooms with locked doors. Because Dr Maiello helped him to bear his frustration about this, imagination could develop. Imagination is a healing psychic process. It helps to heal the wounds caused by frustration and disappointment.

Psychosomatic illnesses When patients are encased in their autistic protection, they are rarely, if ever, physically ill. As they emerge from autism, and their vulnerability is exposed, autistic children begin to have the usual infectious illnesses of childhood, and adult neurotic patients begin to have bodily illnesses. As they lose their autistic protections, they seem to need medical healing as well as psychotherapy. This may indicate, as Dr Grotstein (1983) has suggested, that psychogenic autism is a psychosomatic illness in statu nascendi. O'Gormon (1967) has suggested that hormonal factors may be involved. However, as a psychotherapist, I have only studied psychological factors. Dr Sydney Klein also concentrates on these, when he describes one patient who had a dermoid cyst which had to be cut out. Both the patient and Dr Klein saw this as being a bodily dramatization of an encysted autistic part of her personality from which she needed to be cut off. Another patient developed an inflamed ovarian cyst. Dr Klein saw these

306 AUTISTIC BARRIERS IN NEUROTIC PATIENTS cysts as encysted autistic parts of the self which had been dealt with in a somatic way. Dr Joyce McDougall, a French psychoanalyst who 'has studied psychosomatic illness very intensively, speaks of a 'robot' part of the personality as being at the root of such illnesses (1980). She does not use the word autism, but is obviously aware of the 'backward pull to the inanimate', as Freud called it (Freud, 1920). It is interesting that at many points in studying autism we are led back to Freud. As well as the 'backward pull to the inanimate', we also become aware of the disastrous effect of buried traumas to which Freud alerted us, although the infantile illusory traumas which have been significant in the development of psychogenic autism take place earlier than those that Freud wrote aboyt. Also, in his 'Fragment of an analysis of a case of hysteria' (1905), Freud recognized the importance of the nipple, after which time it was virtually ignored in psychoanalytic literature for about sixty years, until Meltzer (1963) and Bradley (1973) revived interest in its significance.

The value of a study of psychogenic autism Apart from enabling us to be more closely in touch with psychogenic autistic children so that some of them may be helped to more normal functioning, the findings from the study of psychogenic autism promise to deepen our understanding of certain neurotic disorders. Dr Sydney Klein (1980) writes as follows: It is my impression that recognition of the existence of the encapsulated part of the personality reduces the length of the analysis considerably, and moreover may prevent further breakdowns in later life. This was borne in on me when I treated several patients who had been analysed at earlier periods in their lives and who became very disturbed in the course of the process of ageing. There is one other important feature which repays observation in these patients, and indeed in all patients, name-

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ly the process of oscillation which repeatedly occurs, for example, between states of omnipotence and helplessness ... . In connection with this, he describes a manic patient who 'talked incessantly as a defence against feelings of emptiness'. It occurs to me that such talking could also have been an attempt on the part of the patient to 'talk herself through' panic states such as have been described in other chapters in this book. The so-called 'panic states' in otherwise normal individuals are very like those experienced by psychogenic autistic children as they emerge from their autistic encapsulation. This encapsulation has been a protection against such panic. Neurotic patients in panic states complain about not being able to breathe, of feeling that the ground will open beneath their feet, of a sense of impending catastrophe, of a terrible feeling of lassitude. They often find it helpful to 'talk themselves through' such panic states, or to have someone to talk to. Certainly, the 'talking cure', as one of Freud's patients called psychoanalysis, seems relevant to the alleviation of the panic states. of psychogenic autism, both in autistic children and in neurotic adults with a capsule of psychogenic autism. Findings from psychotherapy with psychogenic autistic children promise to add to our understanding of such panic states. As has been indicated at various places in this chapter, they also promise to deepen our understanding of psychosomatic illnesses, psychopathic personalities, addictions, hysteria, certain phobias and cyclothymic states. In my clinical experience, psychogenic autism is liable to crack in situations of biological change such as puberty, after the honeymoon period of marriage, the midlife crisis, and ageing or bereavement. The unmodified vulnerability against which the autism has been a protection is laid bare. This can also sometimes occur after an analysis is terminated. In working with adult neurotic patients with a hidden capsule of autism, it is difficult to ensure that all the autism is being brought within the reflective care of the psychoanalyst's attention. Patients

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sometimes find that when the analysis is over, they have to work over residues of autism which have been undetected. These are often people who, as infants, had to take care of a bewildered and confused mother, or a mother who was mourning the loss of a former child. Usually the father's influence has not been sufficiently felt. These patients were not able to mourn as infants, and this unworked-over mourning can often only be worked over when the analysis has finished. Also, such patients have tended to try to do the analysis for themselves in order to spare the analyst. Thus, the wounds of separation have not been healed as much as they could have been. In this situation, they have to use what they have learned from their experiences of vacations and weekends in the analysis, to help them to come to terms with the mourning that assails them when they lose the bodily presence of their analyst for good. Perhaps this damaged wayward part is never completely healed but, by facing and giving up our autistic bluffs, and by becoming more capable of robust creative interactions with the possibilities of life, we prepare ourselves for the caesura of death, and muster the necessary courage to face it.

CONCLUDING REMARKS

T

his book has sought to add to the psychoanalytic understanding of the psychopathology and development of autistic states. A simple, almost colloquial style has been used as seeming most appropriate for the crude, basic elements which have been discussed. Technical terms have been kept to a minimum. I have learned a great deal from working directly with autistic children. It has become clear to me that autistic patients have become trapped in a chain of psychophysical reactions from which they feel that they cannot escape. T o help them to get free from these is an arduous and painful process for all concerned. When working with autistic children we must not raise false hopes in parents who have already suffered so much. This. book has highlighted some of the difficulties, and also some of the possibilities of psychotherapy with carefully selected, usually young, autistic children. It has also sought to

310 AUTISTIC BARRIERS IN NEUROTIC PATIENTS

throw light on those adult neurotic patients whose mental and emotional life has been impeded by autistic barriers erected in early infancy. Psychotherapy is a scientific art. Science is the study of the regularities of the network of sequence and associations which we call causation. In working with our patients this is what we are studying. We are scientific in our attempts to understand the nature of the disorder we are dealing with (although not exactly in the manner of the natural sciences), and we are artistic in resonating with our patients so that we can help them to change. In doing this, we are challenging as well as tactful. The format of this book has tried to convey this marriage of both science and art. There is a saying that 'It is better to light one small candle than to go on cursing the darkness.' It has been my privilege to light 'one small candle' to shed its light on the dark scene of psychogenic autism. With my advantages and opportunities, it would have been a professional dereliction not to attempt to do so.

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Place of publication is London unless otherwise indicated.

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Frith, U. (1985)'Does the autistic child have a "theory of mind"?', Cognition 21 :37-46. Furneaux, 9. and Roberts, 9 . (1977)Autistic Children. Routledge. Gaddini, E. (1969) 'On imitation', Int.J. Psycho-Anal. 50:475-84. Gaddini, R. (1978)'Transitional object origins and the psychosomatic symptoms', in S. Barkin and H. Berger, eds, Between Fantasy and Reality. New York: Jason Aronson. Gaddini, R. and Gaddini, E. (1959) 'Rumination in infancy', in L. Jessner and E. Pavenstedt, eds, Dynamic Psychopathology in Childhood. New York and London: Grune & Stratton, pp. 166-85. Gero, G. (1953) 'An equivalent of depression: anorexia', in Greenacre, ed. (1953),pp. 117-39. Golding, W. (1956)PincherMartin. Faber. Greenacre, P. (1970)'Fetish objects', Int. J. Psycho-Anal. 5 1 :447-56. , ed. (1953)qffective Disorders. New York: Int. Univs Press. Greene, G . (1971)A Sort of life. Bodley Head. Greene, J. (1980)Dead Man's Fall. Bodley Head. Grotstein, J.S. (1980) 'Primitive mental states', Contemporary Psychoanalysis 16:479-546. (1983) 'Review of Tustin's Autistic States in Children! Int. Rev. Psycho-Anal. 10:491-8. ,ed. (1983)Do I Dare Disturb the UniverselA Memorial to Wilfred R. Bion. Maresfield Reprints. Gull, W.W. (1873)'Anorexia nervosa', Medical Times and Gazette 2534. Haag, G. (1983)'The mother and the baby in the two halvesof the body', Second World Congress of Infant Psychiatry, Cannes. Hobson, P. (1986) 'The autistic child's appraisal of expressions of emotion', J. Child Psychol. and Psychiatry (in press). Hughes, T. (1970) Wodwo. Faber Paperback. (1972)Crow. Faber. Isaacs, S. (1952) 'The nature and function of phantasy', in Riviere, ed. (1952),pp. 67-121. Jackson, M. (1985) 'A psychoanalytical approach to the assessment of a psychotic patient', Psychoanalytic Psychotherapy 1 :11-22. James, M. (1960)'Premature ego development. Some observations on disturbances in the first three months of life', Int. J . Psycho-Anal.41:22&94. Kanner, L. (1943)'Autistic disturbances of affective contact', Netwous Child 2:217-50. Khan, M.M.R. (1964) 'The concept of cumulative trauma', in Kohon, ed. (1986) pp. 117-35. Klein, M. (1930a)'The importance of symbol formation in the development of the ego', in Lave, Guilt and Reparation and Other U'orks. Hogarth, 1975, pp. 219-32.

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-(1930b) 'The psychotherapy of the psychoses', in Love, Guilt and Reparation and Other Works. Hogarth, 1975, pp.233-5. -,Heimann, P. and Money-Kyrle, R.E., eds (1955) New Directionsin Psychoanalysis. Tavistock. Klein, S. (1980) 'Autistic phenomena in neurotic patients', Int. J. PsychoAnal. 61 :395-401, and in Grotstein, ed. (1983), pp. 103-13. Kohon, G. ed. (1986) The British SchoolofPsychoanalysis: The Independent Tradition. Free Association Books. Kohut, H. (1971) The Analysis of the Self. Psychoanal. Study Child Monograph Series. New York: Int. Univs Press. Lastgue, C. (1873) 'On hysterical anorexia', Medical Times and Gazette 2:265-7. Lorand, S. (1943) 'Anorexia nervosa', Psychosomatic Medicine 5 :282-92. Lucretius ( 9 b 5 0 BC?) Of the Nature of Things. W.E. Leonard, metrical 's 1950. trans. ~ v e r ~ m a nLibrary, McDougall, J. (1980) Plea for a Measure of Abnormality. New York: Int. Univs Press. MacNeice, L. (1966) Collected Poems. Faber. Mahler, M. (1958) 'Autism and symbiosis - two extreme disturbances of identity', Int. J. Psycho-Anal. 39:77-83. (1961) 'On sadness and grief in infancy and childhood: loss and restoration of the symbiotic love object', Psychoanal. Study Child 16:332-51. Maiello, S. (1982) 'Le prime esperienze della spazio in bambini autistico'. Quaderni di Psicoterapie Infantile, 6:85-99. Medawar, P. (1979)Advice to a Young Scientist. Pan. Meltzer, D. (1963) 'A contribution to the metapsychology of manic depressive states', 1nt.J. Psycho-Anal. 44:73-96. Meltzer, D., Hoxter, S., Weddell, D. and Wittenberg, I. (1975) Explorations in Autism. Strath Tay : Clunie Press. Meltzoff, A. and Barton, R. (1979) 'Intermodal matching by human neonates', Nature 282M3-4. Miller, J . (1981) 'The Human Body' (BBC television series). Milner, M. (1956) 'The sense in nonsense: Freud and Blake's "Job"', The New Era (Journal of New Education Fellowship) 37 :1-1 1, and a video presentation under the auspices of the Squiggle Foundation, London. (1969) The Hands of the Liuing God. Hogarth. Mollon, P. (1985) 'The non-mirroring mother and the missing paternal dimension in a case of narcissistic disburbance', Psychoanalytic Ps-ychotherapy 1:35-47. Munrow, D. (1950) 'Discord and resolution', unpublished. Ogden, T.H. (1980) 'The nature of schizophrenic conflict', Int. J . PsychoAnal. 61 513-33. O'Gormon, G. (1967) The Nature of Childhood Autism. Butterworth.

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Spitz, R. (1960) 'The primal cavity: contribution to the genesis of perception and its role in psychoanalytic therapy', Psychoanal. Study Child 10: 215-40. (1963) 'Life and the dialogue', in H.S. Gaskill, ed. Counterpoint. New York: Int. Univs Press, pp. 154-76. Stern, D.(1986) The Interpersonal World of the Infant. New York: Basic. Stroh, G . (1974) 'Psychotic children', in P.A. Barker, ed., The Residential Psychiatric Treatment of Children. Crosby, Lockwood Staples. Sylvester, E. (1945) 'Analysis of psychogenic anorexia in a four-year old', Psychoanal. Study Child 1:167-89. Tischler, S. (1979) 'Being with a psychotic child: a psychoanalytical ap-

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INDEX

'acting out', 81 'adhesive equation', 127 Advice to a Young Scientist [Medawar], 37 aetiology, 28, 5 1 affective development. 21, 216 affective functioning, 26 ageing, 306,307 alann states, 62 alexythymia, 27 allegory, 139 Alvarez, Al, 203 Alvarez, Anne, 222 ancient Celts, 155-156, 282 anorexia nervosa, 88, 168, 198,217,237-267 and autism, 237 clinical material, 239 literature, 238-239 relapses, 238

Anthony, J., 36-37 Antonio (autistic boy), 224234 Anzieu, D., 142,205,228 Ariadne (autistic girl), 269285,290,293-298,300 'atmospheric' children, 72 attachment, 193 Aul,angier, P., 39, 142 authority, 295-296 Alitism and Cl~ildhood Psychosis [Tustin], 35, 85, 126 autistic objects, 30, 37.44, 57, 101-1 18.178 autistic encapsulation of, 288-290 hardness, 63, 107, 127-128, 146-147, 150,299 manipulation of, 278 nature of, 103-108, 115

318

AUTISTIC BARRIERS IN NEUROTIC PATIENTS

autistic objects (continued) origins, 108-1 10, 115, 127128 parts of body used as, 28 1 pathology, 39-40 self-generated, 292 as sensation. 108 two-dimensional, 302 use of, 64-65,104, 110115,291 autistic protections, 290-294, 303,305 autistic shapes, 30, 37, 39,40, 44, 101, 178 in action, 126 in adult psychopathology, 141-156 autistic encapsulation of, 288-290 in childhood psychopathology, 119140 manipulation of, 124, 130 nature of. 141-142 in neurotic adults. 150-151 self-generated, 292 shape-making, 121-124, 292 slippery, 151-153 softness, 63, 128, 146, 147, 150,299 two-dimensional, 302 use of, 64-65.29 1 Autistic Stntes in Chilclreri [Tustinl, 35,42, 126, 135 autochthonous sensation, 3 1 auto-erotism, 59-60, 84, 173 auto-sadism, 59 auto-sensuous objects, 58 auto-sensuous states, 37,42, 44,59 avoidance ~~eactions, 23, 25

'axis wrench' [Plath], 203, 204,210 Balint, E., 189,287-289 Balint, M., 27, 36,44 'basic fault' [Balint, M.], 27, 36 Barrows, K., 146, 157,160 Barton, R., 62, 145, 148 bereavement, 307 Rettelheim, B., 5, 65 Beyond the Pleasure Principle [Freud], 234 Bibring, E., 27, 67,265 Bick, E., xvi, 34, 38, 110, 127, 205,228 Bion, W. R., xiv, xvi, 34, 229, 260,268,284,290 on autistic shapes, 135 on emergence from autism, 168 on function of analyst, 290 notion of maternal reverie, 95, 139 on origin of psychogenic autism, 27, 87-89 on role of mother, 116 on terrors, 99 on thinking, 177, 207, 303 birth: caesura of, 43, 99,210, 224, 283 'psychological', 233 biting, 55, 97, 206, 251-252, 259,264 cheeks, 281, 293,294 sadistic, 60 'black hole', 39.40, 62, 65, 82, 86-88, 144 depression, 43 in mouth, 77, 78 remedying, 30

INDEX 'with nasty prick', 36, 58, 59.79.80 Biven, B. M., 203-205 bladder control, 69 bleeding, 198, 218, 255 Bleuler, E., 37 bodily separateness, 96-99, 109, 176,178,180,208 awareness of, 23.4243, 53.88, 193-194,270 as catastrophe, 26 in context of togetherness, 207 realization of, 106, 107, 230 shock of, 63,66, 151,203, 282 toleration of, 56 body image, 220-236 autistic, 301-302 misconceptions, 234 subjective, 23 1 as system of pipes, 227-228 Bollea, C., 35 bowel control, 69 Bower, T. G. R., 42,62, 145, 148 Bowlby, J., xvi, 3.4, 34, 38, 63,298 Bradley, N., 306 brain damage, 20, 22,41, 50, 91 Brazelton, T. B., 42, 60-61, 273 breast, 55, 80, 81, 88, 108, 292,295 as auto-sensuous object, 58 desire for, 74-77 differentiation from mouth of infrmt, 61, 83,284 inf'mt's early experience of, 29, 146 loss of, 105

319

use of, 111, 112 breast-feeding, 69, 80, 84, 86, 240.273 Britislz Jor~rnalof Medical Psycltology, 237 Bronte, A., 190, 302 bulimia, 239 'button' phenomenon, 84.86 case material: see Antonio, Ariadne, Daisy, David, Denis, Dick, Elly, Jean, John, Louise, Marg'uet, Mary, Paul, Peter, Pierre, Sam, Stephen, Steve, Tony castration anxiety, 107 Cattelml, C., 180 Cauquil, C., 142-144,205207,209-214,303 Chasseguet-Smirgel, J., 299 Chomsky, N., 166 Cre,&, M., 35,68 Crick, V., 202,274 circles, 157-164 classification, 84 cognitive defect, 20 acquired, 27-29 innate, 27 cognitive development, 100, 216 early west, 21, 5 1 cognitive functioning, 26, 37 communication, 99, 284 confusional children, 40, 53 see also entangled children continuity of existence, 226227,233 cruelty, 299 Daisy (post-autistic girl), 162, 170-180

320 AUTISTIC BARRIERS IN NEUROTIC PATIENTS dangers, 81-82, 155,224 unconceptualized, 193 David (autistic boy), 102-106 Daws, D., 159-161 De Astis, G., 35 on caesura of birth, 43, 99, 224,283 on onset of autism, 96, 133, 206 death, 25, 179-1 80,254, 271, 282,308 death wish, 92 Decobert, vi dementia praecox, 50 Denis (autistic boy), 6-10 depression, 87, 198,217, 262263,265 anaclitic, 27 elemental, 67 maternal, 60-62,94-97, 163 post-natal, 163, 171 primal, 27.67, 88,237 psychotic, 27,36,67, 88 despair, 165,242, 266, 280, 290 Deutsch, F., 238 Dick (autistic boy), 36, 48-59 disillusionment, 26, 31, 169, 194,224,300 dissolution, 199-205, 208, 212 dissolving, 99, 197-214, 301 D'Ostimi, E. Fe, 35 drawing, 122, 146, 158, 172, 173 dreams, 24-25,78, 112,269, 272,281 dying, fear of, 90 'early infantile autism', 19.22, 36.37.48.187

eating problems, 238-240, 245,249.252.26 1,2632 64 echolalia, 20, 57, 113, 125 echopraxia, 113 ecstasy, 128, 129, 131, 147148, 179,277 ego, 44,45 elation, 187, 189 Eliot, T. S., xiv Elly (autistic girl), 128-13 1, 137, 147, 190 emotional defect, acquired, 27-29 emotional development, 5 1, 100, 102, 178,278,279 empathy, 20, 31, 133, 149 encapsulated children, 22.40, 57,80,205 encapsulation, 24-25.44-46, 201,204,216,233,287 emergence from, 163, 166 exten~al,221 entangled children, 40, 53, 80 see also confusio~lal children e~lvironinentalchanges, 95 Erikson, E., xiv, 110, 149.21 1 Essertfiol Tension [Kuhn], 37 ethology, 38 Ettlinger, N., 288 evil, 275-278 extreme attitudes, 36 eye-to-eye contact, 54, 99 avoidance, 21, 56, 82, 293 Fairbairn, W. R. D., xvi Fall, 25,26,224-225 falling, 23, 25, 183-196 fascination of, 183. 190 fear of, 99, 127, 183, 190,217, 30 1

INDEX threat of, 193-196 fantasies, 226.26 1,282 of child, 103-104, 110112, 117, 192,226,261, 281 of mother, 96.98 father, 99, 113, 132-133,206, 209,270 absence, 94, 132,265 authority, 295-296 hatred for, 241 hostility towards, 266 influence, 308 fetishism, 118 fidgeting, 143 floating state, 223-224, 226 'flowing-over-at-oneness', 224 foetus, 98 food, 49.55, 69,250,261; see also eating problems Fordham, M., 39 forgetting, 199, 202, 218 'fragile chrotnosome', 20 Freud, S., 8,38, 143,205 on autism, 27,306 on 'backward pull to the inanimate', 294, 306 on birth, 210 on narcissism, 59 on play, 234 on reality principle, 260 Fritll, U., 21, 192 frustration, 112, 130, 133, 212,226, 228 avoidance, 87 toleration, 111 fusion, 203, 208 Gaddini, E., 118, 122, 128, 146, 157,219 Gaddini, R., 117, 122

321

Gault, S., 97 geometrical shapes, 161-163, 167 Gero, G., 263 Giannotti, A., vi, 35 on caesura of birth, 43, 99, 224,283 on onset of autism, 96, 133, 206 'going-on-being', 23, 24, 99, 176, 189,276 Great Ormond Street Children's Hospital, London, 35,68 Greeks, 156 grief, 58-59,67, 80, 179 Greenacre, P., 118 Greene, J., 208, 212 Grotstein, J. S., xiii-xx, 27, 98,272,305 growth, 279 Gull, W. W., 238 Haag, G., vi, 146, 157,225 hallucinations, 112 audito~y,142 scl~izophre~~ic, 39 tactile, 39, 142 visual, 125, 142 Hnmilton, V., vi healing, 279, 283, 302-305 hearing, 142 Hobson, P., 3, 20, 133, 192 'holding situation', 70, 76, 88-90 hotnosexual tendencies, 84 hospitalization, 50 Hoxter, S., 126 Hughes, T., xiv, 200-202, 301 hyperactivity, 171, 174, 175 identity, 20.44.215, 217

322 AUTISTIC BARRIERS IN NEUROTIC PATIENTS illusion, 111, 112, 218, 224 Image and Appearance of the Human Body [Schilder], 234 imagination, 31, 149, 192, 282 development of, 226, 305 lack of, 21, 125 imaging, 216-217 'imitative fusion', 128 immobilization, autistic, 2427 impulsivity, 88, 235 individuation, 20 'I-ness', development of, 215236 infantile transference, 64,75, 165, 166,194,273, 300 as healing medium, 3 1, 38, 177 innate forms, 85-86, 166-167 Institute of Childhood Neuropsychiatry, Rome, 35,52,133,206 intangibles, 278 integration, 100 Internatiortal Review of Psycho-Analysis, 30, 102, 119 in utero disturbances, 98 investigative methods, 23 Isaacs, S., 53 Iselin, L., vi Jackson, M., 298 James, M., 234 jealousy, 212,277 Jean (anorexic girl), 197-202, 217-220,225 John (autistic boy), 30,36,39, 58-59, 68-93.209, 292 Journal of Cltild Psyclrology and Psycltiatry, 67

Journal of Child Psychotherapy, 48 Jung, C. G., 166

Kafka, F., 221 Kanner, L., xiii, 19-20.22, 36, 48-50,52,61, 187 -type autism, 50 Kaufman, M. R., 238 Khan, M., 95 Klein, J., 97 Klein, M., xiv, xvi, 242, 260 on projective identification, 168,303 on psychogenic autism, 36, 148-157,59, 63,66, 146, 268 on unconscious ph~ltasies, 166,305 Kleininn psychoanalytic technique, 36, 38 Klein, S., xviii, 7, 14, 15, 25, 242 on encapsulation, 45, 306 on neurotic patients, 100, 168, 181, 196,215, 301 on psycl~oa~alysis, 278 on psycl~oso~natic illness, 305-306 Kohut, H., 60 Kuhn, T., 37 language, 57, 111, 166 Lasegue, C., 238 learning difficulties, 269, 282 Levis, E., 170-179 locotnotor development, 69 loneliness, 99, 130 Lorand, S., 262 loss feelings, 59, 104 Louise (autistic girl), 227228

INDEX

MacNeice, L., xiv, 197,200, 202,212 Mdller, M., xiii, xiv, xvi, 37, 39,53,104, 141 on autistic shapes, 148 on 'black hole', 36 on emergence from autism, 168,303 on grief, 58, 67,90 on 'psychological birth', 233 on separation, 20 Maiello, S., 225-232,301, 305 manic defence, 26 Margaret (anorexic girl), 237267 Mary (autistic woman), 150153, 159 masturbation, 125, 25 1 'maternal preoccupation', 63, 95,284 Maufras de Chuellier, A., vi, 221-222,227 McDougall, J.. 2, 306 Medawar, P., 33,37-38,40 Meltzer, D., xiii, xiv, xv, xvi, 34.61, 127,229,306 Meltzoff, A., 62, 145, 148 'me-ness', 55, 224,277 menstruation, 198,240,249, 254,260,261 metaphors, 139, 145, 167, 282 Mexican earthquake (1985), 28,291 mid-life crisis, 307 Miller, J., 138,216,222, 230, 234-235 Milner, M., 88, 139-140, 200, 280 mirrors, 23 1

323

modification of autism, 3 1-32 Mollon, P., 296 Morrison, J., 3 Morton, R., 238 mother 'alpha function', 139 as autistic shape, 173 'blacked-out', 65 body of, 56 as 'container', 88 depressed, 60, 94-98, 163, 171, 179 hostility towards, 241, 251, 254-255,263 r n o u ~ ~ ~ i308 ng, non-responsive, 61 obsessional, 277 over-dependence on, 270 relationship with child, 64, 113, 164, 173,264-266 separation from, 23, 25,26, 43,51,298 suckling, 23, 27, 29, 108, 250, 292, ultraresponsive, 63 underconfident, 108, 132 undermining situations, 9496,295 unresponsive, 167, 253 mourning, 28, 58-59, 90-91, 296-297.308 mouth, 54, 69,70,75,77-79, 144 differentiated from breast, 58, 61, 83,284 Munrow, D., 183-196 musical shapes, 162-164 37mutative understmdi~~gs, 42 narcissism, 45, 59, 60 Nwh, D.. 154-156,282 neuromentnl system, 44

324 AUTISTIC BARRIERS IN NEUROTIC PATIENTS neurotic patients, 100-101, 106, 166 adult, 150-151, 190,268, 287-289,299-301,307 with capsule of autism, 151, 168, 195, 197,204,215216,287-289,298-300 Newman, A., vi Newm,m, M., vi nightmares, 74 nipple-seeking, 84 see also breast, breastfeeding non-autistic shapes, 160-161 nose-picking, 73 'not-me', 128, 132, 138, 277 'blacked-out', 304 hard, 305 and 'me', 55, 57, 162,276 terror of, 58 threats, 22 numbers, 130, 148 Ogden, T. H., 298 O'Gormon, G., 305 Olin, R., 96 omnipotence, 249, 250,265, 307 organic autism, 19-20, 91 'out-of-the-body' experiences, 25, 189 over-concretized thinking, 25 panic states, 307 paralysis, 187 parental neglect, 20 Park, D., 128 Paul (autistic boy), 48,49 penis, 79, 83, 85,262 envy of, 260,264 handling of, 70,7 1, 73, 77 perception, 161, 190, 192, 292

beginnings, 84, 92 primitive modes, 148 peripheral vision, 154 Persori arid Psychosis [Resnik], 172 personal pronoun, 73,2 15, 225 perversion. 299 Peter (autistic boy), 103, 104, 135-139, 147, 149 phantasies, 53, 261 phobias, 26 physical development, 21 Piaget, J., 84 Piell'e (autistic boy), 221-223, 225 Piggott, L. R., 22, 187 Plath, S., xiv, 202-204,210 'polar chill', 203, 204 Popper, K., 38 predators, fear of, 63-64 pregnalcy, 98,248, 250,261, 262,266 phantasy, 249, 254,258, 26 1 'primal sulk', 194 'primal unity', 224 primeval terrors, 63-66 primordial shapes, 144, 148150 projective identification, 53, 168,303 psychic functioning, 28 psychic work, 298 psycho~~alysis, 52, 133-140, 225,262,286-308 psychodynamic treatment of autism, 20 psychogenic autism, 40, 42, 192-193 development, 67-93 effects, 298-301

INDEX emergence from, 157-169, 187,294,305,307 nature of, 19-32,44 origins, 22-24.59 precipitation, 59, 94-101 psychopathology, 53,268 psychotherapy, 92-93, 101, 286-287,308 treatment, 33, 115,287-308 psychogenic damage, 22 psychological tests, 54 psychomorphology, 125 psychoses, 45,51, 66, 68,298 psychosomatic illness, 216, 305,307 psychotllerapy, 31, 68, 84,98 in anorexia, 239 difficulties, 309 effectiveness, 30 possibilities, 309 psychoanalytic, 41, 133140,286 in psychogenic autism, 9293, 101, 117, 126, 191, 286-308 scientific art, 3 10 Putnarn, M., 67 Putnm Children's Center, Boston, MA, 34 Rallman, L., 238 Rank, B., 67 'raw beta elements', 139 reality: baniers to, 111 bridges to, 111 detachment from, 185 as disillusionment, 194 evasion of, 283 inner, 230 outer, 230 representation of, 100

325

reality principle, 164-166, 260,266 'refrigerator mothers', 61 regression, 50-5 1, 254 religious experiences, 284 representational activities, 74 Resnik, S., 172 retreat into autism, 289-290 reverie, 89, 95, 135, 139, 236, 2 84 Richardson, H. B., 238 Ricks, D., 111 Riley, C., 10, 11 Ripley, H. F., 238 rivalry, 219, 257 rocking, 131-132, 206 Rosenfeld, D., 100,228 Rosenfeld, H., 34,45,298 'rubber stamping', 222 Rubinfine, D. L., 98 Sade, Marquis de, 299 safety, 95 rhythm of. 268-285, 296 Sam (autistic boy), 158, 165 Sandler, J., 272 Sutre, J. P., 208 Schilder, P., 234 schizophrenic-type disorders, 20,36,40,45, 50, 53 in adults, 142 Scott, C., 238 screaming fits, 70, 74,76-79, 159, 163 scribbling, 143, 158, 160, 206 Segal, H., 54, 105,291 on symbol fot-mntion. 59, 74, 139,278 self, 44 false, 44,45 'felt', 216, 221-223, 225 sense of, 44, 60, 146

326 AUTISTIC BARRIERS IN NEUROTIC PATIENTS 'self-object', 39 self-representation, 216, 232 sensations, 54, 190,223-226 separation, 20,23, 27,42-43, 62, 85-86 in early infancy, 298 primal, 101 psychological, 64, 155, 299 sexuality, 260-262, 284 'shell-type' children, 22, 57, 205 sight, 120, 142, 145, 150 Simon, P., 237 skin, 228, 301, 304 sleeping problems, 70, 80,260 smell, 120 sociability, 56 sound, 120, 150 space, 55 speech, 49,54,76, 87, 162 lack of, 68, 125 Spensley, S., 41 spilling, 99, 127, 197-214, 220 fear of, 197,208,212, 301 spitting, 73 Spitz, R., 27,40, 63, 223 'startle response', 62 Stephen (autistic boy), 21-22, 154 Stem, D., 23 Steve (autistic boy), 142-143, 147.205-214.303 sticking, 144 Stroh, G., 113, 134 Structure of Scierttific Revolutions [Kuhn], 37 Subirana, V.. vi 'subjective-object', 39 sucking, 43, 58,60,97,99, 111

cheeks, 281, 293 difficulty in, 49, 55, 56, 69 thumb, 165, 208 suckling, 29-30. 164 suicide, 294, 299 survival, 55,213 psychic, 291 Sylvester, E., 263,266 symbiotic children, 80 symbol formation, 59, 117, 192 syrlibolic equations, 74, 139, 27 8 tactile reactions, 65 tantlums, 73, 128, 131, 147148, 195,266,277 'held', 89 of rage, 56 screaming, 78 of terror, 56, 111 'unheld', 87 taste, 120 Tavistock Clinic, London, 34, 38 'teat-tongue' combination, 82, 295 teething, 95, 97, 206,211 Tennyson, A., Lord, vi, xiv terrors, 171, 187-188, 191, 198,293 atavistic, 284 infantile, 74,75, 90,98, 99, 108, 115 of non-existence, 217, 218, 220 of spilling, 212, 224 thought^, 175-179 time, 56, 162 Tischler, S., 61, 132 togethen~ess,207,247, 303

INDEX toilet training, 50, 87, 122, 206,247 psychological, 223 Tony (autistic youth), 130131, 137, 147 Topiquc, 141 touch, 63, 65, 120, 145 transference relationship, 242, 243,246,251 transitional objects, 116-1 18 transitional states, 221, 228 Trevarthen, C., 42 triangles, 159, 161, 163 Tustin, F., xiv-xix, 5, 36, 104, 144, 166,215,224 unreality, 185 Waller, J. V., 238 weaning, 49,55,97,265 weight changes, 238-267 Weiszaecker, B. von, 262 Whan, M., 199 Winnicott, D. W., xiv, xvi, xix, 6, 31,51,55,268

327

on autistic objects, 1lO112, 116-1 18, 128, 168 on autistic shapes, 139140, 154 on 'black hole', 36, 58, 144 on depression, 27, 36,39, 67, 87 on 'false self', 44 on 'holding situation', 70, 76, 88, 90 on illusion, 224 on 'maternal preoccupation', 63,95, 284 on separation from mother, 23 on terrors, 99, 104 on tr'msitional states, 221, 304 womb, 63,210 words, 105, 174,243 as autistic objects, 113 Yeats, W. B., xiv, 296 Youderian, P., 128