Frances Tustin Today

Home , Come Upstairs, Dual Unity, Fear of ghosts, Playing Possum, Separation Anxieties

Downloaded by [New York University] at 03:54 14 August 2016 Frances Tustin is an icon within British Object-Relations psychoanalysis. It is good to have in this book a sustained tribute to her ideas and to their significant and enduring contribution. Her tradition of learning fundamental truths from autistic conditions remains lively, productive and inspiring. Tustin’s work sustains one of the founding principles of Object-Relations work – that the depth of psychoanalytic ideas is enhanced by rigorous work with children. As that long- held view – going back to the innovative work of Anna Freud and Melanie Klein – has weakened over time, granting a more exclusive place to work with adults, it is important to have this book to redress that imbalance. This collection draws us back to the fundamental questions about working with another mind. How can one conceive of the object relations of a mind that can barely sustain the possibility of relating to others? It is commonplace to regard psychoanalysis as a body of knowledge derived from what goes wrong, but what can be learned about a mind that has gone so radically and despairingly wrong? It is evident from the wide range of papers presented here that indeed much can be learned from the work with children, contributing that which is not accessible in the work with adults alone. This book is a celebration of clinical and therapeutic confidence from those who have actually persevered in the presence of severe autism, those who have managed to form a joint venture with their suffering young patients, both large and small. — Bob Hinshelwood, Professor, Centre for Psychoanalytic Studies, University of Essex

The editors of Frances Tustin Today have done a wonderful job of bringing together an exciting collection of some of the most important writings illustrating Tustin’s extraordinary influence on contemporary psychoanalytic work, particularly regarding the entire autism spectrum. The book may be likened to a string of pearls. The single pearls, like the single articles, are precious in their own right, yet when strung together they form an entirely new and even more valuable reality. The book, in my view, presents an invaluable harvest of ideas that will inspire and motivate future developments in a field as controversial as it isimportant – indeed there is a growing awareness that we all experience autistic trends to one degree or another. In short, Frances Tustin Today is highly recommended to anyone wishing to delve more deeply into primitive mental states in the directions Downloaded by [New York University] at 03:54 14 August 2016 pointed out by Bion. — Antonino Ferro, Italian Psychoanalytic Society

This book is essential reading for those interested in autistic states and the dimension of autosensuality and autosensual protections in mental states of mind. It shows both Tustin’s own theoretical development and her influence on contemporary thinkers from around the world. — Dana Birksted-Breen, PhD, Editor-in-Chief, International Journal of Psychoanalysis This page intentionally left blank Downloaded by [New York University] at 03:54 14 August 2016 Frances Tustin Today

Frances Tustin Today explores some of the ways and means by which Tustin’s work has enabled psychoanalytic clinicians to enter into the elemental domain of sensation: what Bion called the ‘proto-mental’ area of the psyche-soma. Through detailed clinical contributions of several of her exponents worldwide, this book demonstrates how her ideas – rooted in decades of work with children on the autistic spectrum – have influenced and are being expanded, extended and applied to the treatment of ordinary patients from early childhood through adulthood. The contributors to this volume represent a selection of the contemporary thinking that organically grew out of Tustin’s discoveries, and show that Tustin’s model has added new dimensions to the fields of infant observation, family therapy and neuro-psychology. Each chapter is augmented by demonstrable clinical experience. Frances Tustin Today is a valuable resource for psychoanalysts, psychotherapists, educators and parents who are interested in learning more about this uniquely independent clinical observer’s findings and their impact upon the treatment of autistic states in children, adolescents and adults by contemporary workers in the field of mental health.

Judith L. Mitrani and Theodore Mitrani are Fellows of the International Downloaded by [New York University] at 03:54 14 August 2016 Psychoanalytical Association, and training and supervising psychoanalysts at the Psychoanalytic Center of California in Los Angeles. They are founding members of the Board of Trustees of the Frances Tustin Memorial Trust, and authors, editors, translators and teachers in the private practice of psychoanalysis and psychoanalytic therapy with adults and children in Los Angeles, California. This page intentionally left blank Downloaded by [New York University] at 03:54 14 August 2016 The New Library of Psychoanalysis General Editor: Alessandra Lemma

The New Library of Psychoanalysis was launched in 1987 in association with the Institute of Psychoanalysis, London. It took over from the International Psychoanalytical Library which published many of the early translations of the works of Freud and the writings of most of the leading British and Continental psychoanalysts. The purpose of the New Library of Psychoanalysis is to facilitate a greater and more widespread appreciation of psychoanalysis and to provide a forum for increasing mutual understanding between psychoanalysts and those working in other disciplines such as the social sciences, medicine, philosophy, history, linguistics, literature and the arts. It aims to represent different trends both in British psychoanalysis and in psychoanalysis generally. The New Library of Psychoanalysis is well placed to make available to the English-speaking world psychoanalytic writings from other European countries and to increase the interchange of ideas between British and American psychoanalysts. Through the Teaching Series, the New Library of Psychoanalysis now also publishes books that provide comprehensive, yet accessible, overviews of selected subject areas aimed at those studying psychoanalysis and related fields such as the social sciences, philosophy, literature and the arts. The Institute, together with the British Psychoanalytical Society, runs a low-fee psychoanalytic clinic, organises lectures and scientific events concerned with psychoanalysis and publishes the International Journal of Psychoanalysis. It runs a training course in psychoanalysis which leads to membership of the International Psychoanalytical Association – the body which preserves internationally agreed

Downloaded by [New York University] at 03:54 14 August 2016 standards of training, of professional entry and of professional ethics and practice for psychoanalysis as initiated and developed by Sigmund Freud. Distinguished members of the Institute have included Michael Balint, Wilfred Bion, Ronald Fairbairn, Anna Freud, Ernest Jones, Melanie Klein, John Rickman and Donald Winnicott. Previous general editors have included David Tuckett, who played a very active role in the establishment of the New Library. He was followed as general editor by Elizabeth Bott Spillius, who was in turn followed by Susan Budd and then by Dana Birksted-Breen. Current members of the Advisory Board include Liz Allison, Giovanna di Ceglie, Rosemary Davies and Richard Rusbridger. Previous members of the Advisory Board include Christopher Bollas, Ronald Britton, Catalina Bronstein, Donald Campbell, Sara Flanders, Stephen Grosz, John Keene, Eglé Laufer, Alessandra Lemma, Juliet Mitchell, Michael Parsons, Rosine Jozef Perelberg, Mary Target and David Taylor.

Titles in this series Impasse and Interpretation Herbert Rosenfeld Psychoanalysis and Discourse Patrick Mahony The Suppressed Madness of Sane Men Marion Milner The Riddle of Freud Estelle Roith Thinking, Feeling, and Being Ignacio Matte Blanco The Theatre of the Dream Salomon Resnik Melanie Klein Today: Volume 1, Mainly Theory Edited by Elizabeth Bott Spillius Melanie Klein Today: Volume 2, Mainly Practice Edited by Elizabeth Bott Spillius Psychic Equilibrium and Psychic Change: Selected Papers of Betty Joseph Edited by Michael Feldman and Elizabeth Bott Spillius About Children and Children-No-Longer: Collected Papers 1942–80 Paula Heimann. Edited by Margret Tonnesmann The Freud–Klein Controversies 1941–45 Edited by Pearl King and Riccardo Steiner Dream, Phantasy and Art Hanna Segal Psychic Experience and Problems of Technique Harold Stewart Clinical Lectures on Klein and Bion Edited by Robin Anderson From Fetus to Child Alessandra Piontelli A Psychoanalytic Theory of Infantile Experience: Conceptual and Clinical Reflections E. Gaddini. Edited by Adam Limentani The Dream Discourse Today Edited and introduced by Sara Flanders The Gender Conundrum: Contemporary Psychoanalytic Perspectives on Feminitity and Masculinity Edited and introduced by Dana Breen Psychic Retreats John Steiner

Downloaded by [New York University] at 03:54 14 August 2016 The Taming of Solitude: Separation Anxiety in Psychoanalysis Jean-Michel Quinodoz Unconscious Logic: An Introduction to Matte-Blanco’s Bi-logic and its Uses Eric Rayner Understanding Mental Objects Meir Perlow Life, Sex and Death: Selected Writings of William Gillespie Edited and introduced by Michael Sinason What Do Psychoanalysts Want?: The Problem of Aims in Psychoanalytic Therapy Joseph Sandler and Anna Ursula Dreher Michael Balint: Object Relations, Pure and Applied Harold Stewart Hope: A Shield in the Economy of Borderline States Anna Potamianou Psychoanalysis, Literature & War: Papers 1972–1995 Hanna Segal Emotional Vertigo: Between Anxiety and Pleasure Danielle Quinodoz Early Freud and Late Freud Ilse Grubrich-Simitis A History of Child Psychoanalysis Claudine and Pierre Geissmann Belief and Imagination: Explorations in Psychoanalysis Ronald Britton A Mind of One’s Own: A Psychoanalytic View of Self and Object Robert A. Caper Psychoanalytic Understanding of Violence and Suicide Edited by Rosine Jozef Perelberg On Bearing Unbearable States of Mind Ruth Riesenberg-Malcolm Psychoanalysis on the Move: The Work of Joseph Sandler Edited by Peter Fonagy, Arnold M. Cooper and Robert S. Wallerstein The Dead Mother: The Work of André Green Edited by Gregorio Kohon The Fabric of Affect in the Psychoanalytic Discourse André Green The Bi-Personal Field: Experiences of Child Analysis Antonino Ferro The Dove that Returns, the Dove that Vanishes: Paradox and Creativity in Psychoanalysis Michael Parsons Ordinary People, Extra-ordinary Protections: A Post Kleinian Approach to the Treatment of Primitive Mental States Judith Mitrani The Violence of Interpretation: From Pictogram to Statement Piera Aulagnier The Importance of Fathers: A Psychoanalytic Re-Evaluation Judith Trowell and Alicia Etchegoyen Dreams That Turn Over a Page: Paradoxical Dreams in Psychoanalysis Jean-Michel Quinodoz The Couch and the Silver Screen: Psychoanalytic Reflections on European Cinema Andrea Sabbadini In Pursuit of Psychic Change: The Betty Joseph Workshop Edited by Edith Hargreaves and Arturo Varchevker The Quiet Revolution in American Psychoanalysis: Selected Papers of Arnold M. Cooper Arnold M. Cooper. Edited and Introduced by Elizabeth L. Auchincloss Downloaded by [New York University] at 03:54 14 August 2016 Seeds of Illness and Seeds of Recovery: The Genesis of Suffering and the Role of Psychoanalysis Antonino Ferro The Work of Psychic Figurability: Mental States Without Representation César Botella and Sára Botella Key Ideas for a Contemporary Psychoanalysis: Misrecognition and Recognition of the Unconscious André Green The Telescoping of Generations: Listening to the Narcissistic Links Between Generations Haydée Faimberg Glacial Times: A Journey through the World of Madness Salomon Resnik This Art of Psychoanalysis: Dreaming Undreamt Dreams and Interrupted Cries Thomas H. Ogden Psychoanalysis and Religion in the 21st Century: Competitors or Collaborators? David M. Black Recovery of the Lost Good Object Eric Brenman The Many Voices of Psychoanalysis Roger Kennedy Feeling the Words: Neuropsychoanalytic Understanding of Memory and the Unconscious Mauro Mancia Constructions and the Analytic Field: History, Scenes and Destiny Domenico Chianese Projected Shadows: Psychoanalytic Reflections on the Representation of Loss in European Cinema Edited by Andrea Sabbadini Encounters with Melanie Klein: Selected Papers of Elizabeth Spillius Elizabeth Spillius Yesterday, Today and Tomorrow Hanna Segal Psychoanalysis Comparable and Incomparable: The Evolution of a Method to Describe and Compare Psychoanalytic Approaches David Tuckett, Roberto Basile, Dana Birksted-Breen, Tomas Böhm, Paul Denis, Antonino Ferro, Helmut Hinz, Arne Jemstedt, Paola Mariotti and Johan Schubert Time, Space and Phantasy Rosine Jozef Perelberg Rediscovering Psychoanalysis: Thinking and Dreaming, Learning and Forgetting Thomas H. Ogden Mind Works: Techniques and Creativity in Psychoanalysis Antonino Ferro Doubt Conviction and the Analytic Process: Selected Papers of Michael Feldman Michael Feldman Melanie Klein in Berlin: Her First Psychoanalyses of Children Claudia Frank The Psychotic Wavelength: A Psychoanalytic Perspective for Psychiatry Richard Lucas Betweenity: A Discussion of the Concept of Borderline Judy Gammelgaard The Intimate Room: Theory and Technique of the Analytic Field Giuseppe Civitarese Bion Today Edited by Chris Mawson

Downloaded by [New York University] at 03:54 14 August 2016 Secret Passages: The Theory and Technique of Interpsychic Relations Stefano Bolognini Intersubjective Processes and the Unconscious: An Integration of Freudian, Kleinian and Bionian Perspectives Lawrence J. Brown Seeing and Being Seen: Emerging from a Psychic Retreat John Steiner Avoiding Emotions, Living Emotions Antonio Ferro Projective Identification: The Fate of a Concept Edited by Elizabeth Spillius and Edna O’Shaughnessy Creative Readings: Essays on Seminal Analytic Works Thomas Ogden The Maternal Lineage Edited by Paola Mariotti Donald Winnicott Today Edited by Jan Abram Symbiosis and Ambiguity: A Psychoanalytic Study Edited by John Churcher, José Bleger and Leopoldo Bleger Psychotic Temptation Liliane Abensour Supervision in Psychoanalysis: The Sao Paulo Seminars Antonino Ferro Transference and Countertransference Today Robert Oelsner Living Psychoanalysis: From Theory to Experience Michael Parsons Imaginary Existences: A Psychoanalytic Exploration of Phantasy, Fiction, Dreams and Daydreams Ignês Sodré. Edited and with an Introduction by Priscilla Roth The Pioneers of Psychoanalysis in South America: An Essential Guide Edited by Nydia Lisman-Pieczanski and Alberto Pieczanski Minding the Body: The Body in Psychoanalysis and Beyond Alessandra Lemma Inquiries in Psychoanalysis: The Collected Papers of Edna O’Shaughnessy Edna O’Shaughnessy. Edited by Richard Rusbridger Torments of the Soul: Psychoanalytic Transformations in Dreaming and Narration Antonino Ferro

TITLES IN THE NEW LIBRARY OF PSYCHOANALYSIS TEACHING SERIES Reading Freud: A Chronological Exploration of Freud’s Writings Jean-Michel Quinodoz Listening to Hanna Segal: Her Contribution to Psychoanalysis Jean-Michel Quinodoz Reading French Psychoanalysis Edited by Dana Birksted-Breen, Sara Flanders and Alain Gibeault Reading Winnicott Lesley Caldwell and Angela Joyce Initiating Psychoanalysis: Perspectives Bernard Reith, Sven Lagerlöf, Penelope Crick, Mette Møller and Elisabeth Skale Infant Observation Frances Salo

Downloaded by [New York University] at 03:54 14 August 2016 Reading Anna Freud Nick Midgley

TITLES IN THE NEW LIBRARY OF PSYCHOANALYSIS ‘BEYOND THE COUCH’ SERIES Under the Skin: A Psychoanalytic Study of Body Modification Alessandra Lemma Engaging with Climate Change: Psychoanalytic and Interdisciplinary Perspectives Edited by Sally Weintrobe Research on the Couch: Single Case Studies, Subjectivity, and Psychoanalytic Knowledge R. D. Hinshelwood Psychoanalysis in the Technoculture Era Edited by Alessandra Lemma and Luigi Caparrotta Moving Images: Psychoanalytic Reflections on Film Andrea Sabbadini Downloaded by [New York University] at 03:54 14 August 2016 Frances Tustin Today

Edited by Judith L. Mitrani and Theodore Mitrani Downloaded by [New York University] at 03:54 14 August 2016 First published 2015 by Routledge 27 Church Road, Hove, East Sussex, BN3 2FA And by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business. © 2015 Judith L. Mitrani and Theodore Mitrani The right of the editors to be identified as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Frances Tustin today / edited by Judith L. Mitrani and Theodore Mitrani. p. ; cm. I. Mitrani, Judith L., editor. II. Mitrani, Theodore, editor. [DNLM: 1. Tustin, Frances. 2. Autistic Disorder–therapy. 3. Autistic Disorder– history. 4. History, 20th Century. WS 350.8.P4] RC553.A88 616.85’882–dc23 2014037156

ISBN: 978-1-138-82044-9 (hbk) ISBN: 978-1-138-82045-6 (pbk) ISBN: 978-1-315-74388-2 (ebk) Downloaded by [New York University] at 03:54 14 August 2016

Typeset in Times by Deer Park Productions. Contents

Contributors xv Introduction to the life and work of Frances Tustin xxi Theodore and judiTh MiTrani

PART I Prenatality through latency 1

1 The perpetuation of an error 3 Frances TusTin

2 Stuck between two worlds: autistic defenses and the experience of premature birth 19 angela sowa

3 Prenatal trauma and autism 37 suzanne Maiello

Downloaded by [New York University] at 03:54 14 August 2016 4 Further reflections on the construction of the body-ego 54 geneviève haag

5 Finding the wavelength: tools in communication with autistic children 69 anne alvarez xiv Contents

PART II Adolescence through adulthood 81

6 The use of observation in the psychoanalytic treatment of a 12-year-old boy with Asperger’s syndrome 83 Maria e. Pozzi

7 Aspects of the body image and sense of identity in a boy with autism: implications for eating disorders 100 Maria rhode

8 Long-term mother-child psychotherapy: infantile autism with cerebellar anomaly 115 Bianca lechevalier-haïM

9 Autistic phenomena in neurotic patients 134 sydney Klein

10 Precipitation anxiety in the analysis of adult patients 143 didier houzel

11 On the concept of an autistic-contiguous position 155 ThoMas h. ogden

12 Trying to enter the long black branches: some technical extensions for the analysis of autistic states in adults 174 judiTh l. MiTrani Downloaded by [New York University] at 03:54 14 August 2016 13 Ghosts in the swamp: some aspects of splitting and their relationship to parental losses 194 KaTe Barrows

References 209 Index 222 Contributors

Anne Alvarez, PhD, MACP, trained as a clinical psychologist in Canada and the USA before training as a child and adolescent psychotherapist at the Tavistock Centre. She is an honorary consultant child and adolescent psychotherapist and retired Co-Convener of the Autism Workshop, Child and Family Department, at the Tavistock Clinic, London. She is the author of numerous papers and best known for her book Live Company: Psychotherapy with Autistic, Borderline, Deprived and Abused Children. She has also edited (with Susan Reid) Autism and Personality: Findings from the Tavistock Autism Workshop. A book in her honour, edited by Judith Edwards, entitled Being Alive: Building on the Work of Anne Alvarez, was published in 2002. Her most recent book is The Thinking Heart: Three Levels of Psychoanalytic Therapy with Disturbed Children. Kate Barrows is a training analyst with the British Psychoanalytical Society and works in private practice in Bristol, England. She is also a Tavistock- trained child psychotherapist and works at the Bridge Foundation for Psychotherapy and the Arts. She writes on a variety of clinical topics and has published several papers about the relationship between literature and psychoanalysis. These include: ‘Shadow Lives’, in A Festschrift for H. Sydney Klein, edited by J. Symington and published by Karnac Books, London and New York (2000); and ‘Aspects of Love and Loss in Three of Shakespeare’s Sonnets’, in Acquainted with the Night, edited by H. Canham and C. Satyamurti, in the Tavistock Clinic Series and published by Karnac Books, Downloaded by [New York University] at 03:54 14 August 2016 London (2003). Her clinical writings include papers in books and journals and the book Ideas in Psychoanalysis: Envy (2002). She was also the editor of Autism in Childhood and Autistic Features in Adults (2008). Geneviève Haag is a psychiatrist and adult and child psychoanalyst in private practice in Paris. A member of the Psychoanalytic Society of Paris, she is also a Founding Member of GERPEN (Research and Study Group for Child and Infant Development) established in 1983. In 2004 she founded CIPPA (International Association of Psychoanalytic Psychotherapists working with Autistic Patients). Since 2008 Dr Haag has been working within the INSERM xvi Contributors

Network of Clinically Based Research on Psychotherapy (established by J. M. and M. Thurin and B. Falissard). In 2013 this organisation submitted an initial report to the French Ministry of Health on fifty cases that demonstrate the decidedly positive effects of psychoanalytic psychotherapies. She is a past President (1993–2012) of the Scientific Council ‘La Clé pour l’Autisme’, an association of parents which has founded establishments for autistic children and adults. She received the Kestemberg Award in recognition of her multiple contributions to the study of autism and body image. She is a Chevalier of the Légion d’Honneur.

Didier Houzel is a French psychiatrist and psychoanalyst specialising in the psychoanalysis of children in the tradition of Melanie Klein, Wilfred Bion and Frances Tustin and uses the psychoanalytic observation techniques developed by Esther Bick. He is Professor of Child and Adolescent Psychiatry at the University of Caen and head of the Department of Psychiatry at the University Hospital of Caen; co-editor of the Journal de la Psychanalyse de l’Enfant; and the author and/or co-editor of numerous papers and books. These include The Concept of the Psychic Envelope, L’Enfant, Ses Parents et le Psychanalyste, Invisible Boundaries: Psychosis and Autism in Children and Adolescents, and Dictionnaire de Psychopathologie de l’Enfant et de l’Adolescent. Dr Houzel was awarded the Frances Tustin Memorial Prize in 2002.

Sydney Klein (1918–2005) was a Founder Fellow of the Royal College of Psychiatrists and a training analyst with the British Psychoanalytical Society, where he was a member of the Melanie Klein Group. He was also a child analyst and served as Director of the Children’s Department at the London Clinic of Psychoanalysis. He was regarded as one of the finest clinicians of his day, and treated patients whose difficulties were at the margins of analysabil- ity; he was convinced that analysis could and should be used to reach extremely ill patients who might not be helped by other means. He supervised Frances Tustin on one of her first autistic patients at the West Middlesex Hospital; she felt that this was a formative experience that helped her at the start of her work and writing about autistic children. Klein was himself the first psychoanalyst to write about autistic aspects of adult neurotic patients. A

Downloaded by [New York University] at 03:54 14 August 2016 Festschrift in his honour (Imprisoned Pain: A Festschrift for H. Sydney Klein, ed. J. Symington) was published in 2000 by Karnac. Bianca Lechevalier-Haïm practises psychoanalysis with both adults and children in Caen, France. She is a psychiatrist and a training and supervising analyst of the Paris Psychoanalytical Society. Formerly Senior Registrar in Neuro-Psychiatry in the Paris University Medical School, and Senior Lecturer in Psychopathology at the University of Caen, she has published various papers about autism, psychosomatic diseases, countertransference and the consequences of the Shoah in journals and edited collections as well as in two books: Le Corps et le Sens: Dialogue Entre une Psychanalyste et un Contributors xvii

Neurologue and Les Contes et la Psychanalyse. Dr Lechevalier-Haïm was awarded the Frances Tustin Memorial Prize in 2003. Suzanne Maiello is a child and adult psychoanalytic psychotherapist practising in Rome, Italy. She is a member of the Italian Association of Psychoanalytic Psychotherapy (AIPPI) where she is an organising tutor in the Infant and Early Childhood Service of the Clinical Center. She was awarded the Frances Tustin Memorial Prize in 1997. She teaches on Italian courses leading to the MA in Psychoanalytic Infant Observational Studies with the Tavistock Clinic/ University of East London, and also teaches Infant Observation in Berlin, Toulouse and Santa Fe. Her published work, particularly her very original seminal studies on pre-natal auditory states, is well-known. Judith L. Mitrani is a Fellow of the International Psychoanalytical Association, a training and supervising analyst at the Psychoanalytic Center of California and the Founding and present Chair of the Frances Tustin Memorial Trust. She is the author of the books Framework for the Imaginary: Clinical Explorations in Primitive States of Being and Ordinary People and Extraordinary Protections: A Post-Kleinian Approach to the Treatment of Primitive Mental States, and is also the co-editor of the book Encounters with Autistic States: A Memorial Tribute to Frances Tustin. Her new book, Psychoanalytic Technique and Theory: Taking the Transference, is in press (2015). She has published papers in seven languages and practices psychoanalysis with adults in West Los Angeles. Theodore Mitrani is a Fellow of the International Psychoanalytical Association, and a training and supervising analyst in both the Adult and Infant, Child and Adolescent core training programs at the Psychoanalytic Center of California in Los Angeles. He is the current Co-Chair of the Infant, Child and Adolescent Training Committee and an instructor in Borderline and Psychosis, Child Analysis, Psychoanalytic Technique and Clinical Case Conferences. He is also an international lecturer on many topics regarding the analysis of primitive states. He is the co-editor of the book Encounters with Autistic States: A Memorial Tribute to Frances Tustin and practices psychoanalysis with children, adolescents and adults in West Los Angeles.

Downloaded by [New York University] at 03:54 14 August 2016 Thomas H. Ogden is a Supervising and Personal Analyst at the Psychoanalytic Institute of Northern California and a member of the faculty of the San Francisco Center for Psychoanalysis. He has served on the editorial boards of a number of major psychoanalytic journals, including the International Journal of Psychoanalysis. In 2004 Dr Ogden was awarded the International Journal of Psychoanalysis Award for the ‘Most Important Paper of the Year’ and in 2010 he was honoured with the Haskell Norman Prize for ‘Outstanding Achievement in Psychoanalysis’. In 2012 he was presented the Sigourney Award for his contributions, which include ten books and over 100 papers. Dr Ogden teaches, practises and supervises in San Francisco. xviii Contributors

Maria E. Pozzi trained as a child and adolescent psychotherapist at the Tavistock Clinic and as an adult psychotherapist at the British Association of Psychotherapists. She has special interests in treating children with autism, Asperger’s syndrome and mental handicap and also in brief psychotherapy with children under five and their families. She was awarded the Frances Tustin Memorial Prize in 1999 and is the author/co-author of many published papers and the books Psychic Hooks and Bolts: Psychoanalytic Work with Children Under Five and Their Families (2003), Innovations in Parent-Infant Psychotherapy (2010) and The Buddha and the Baby: Psychotherapy and Meditation in Working with Children and Adults (2014). She is in private practice in London. Maria Rhode is Emeritus Professor of Child Psychotherapy at the Tavistock Clinic and the University of East London, and Honorary Associate of the British Psychoanalytic Society. She is an Honorary Consultant Child Psychotherapist at the Tavistock Clinic, where she formerly co-convened the Autism Workshop and where she has worked to develop an early intervention project for toddlers at risk of autism. She lectures and publishes widely and is co-editor of Psychotic States in Children, The Many Faces of Asperger’s Syndrome and Invisible Boundaries: Psychosis and Autism in Children and Adolescents. She was awarded the Frances Tustin Memorial Prize in 1998. Angela Sowa is a psychoanalyst, psychotherapist and consultant. She earned her doctorate from the Psychoanalytic Institute of Northern California where she is currently a personal and supervising analyst and faculty member. She is also assistant clinical faculty at the University of California at San Francisco and teaches courses on dreams, infancy and psychosomatics for several institutes and professional organisations including the Northern California Society for Psychoanalytic Psychology, Palo Alto, Psychoanalytic Psychotherapy Training Program, Access Institute and Santa Clara University. For many years she has been involved as an observer and leader of Tavistock model infant observation groups. She has published on the topics of psychoanalysis and infant observation, is a member of a reproductive technology research group

Downloaded by [New York University] at 03:54 14 August 2016 and consultant to Lucille Packard Children’s Hospital Neonatal Intensive Care Program. She works analytically with both individuals and couples in the South San Francisco Bay area and is a perinatal consultant with a special interest in the care and outcome of premature infants. Frances Tustin was a pioneering child psychotherapist, world renowned for her work with autistic children. She undertook her psychotherapy training in 1950 in the children’s department of London’s Tavistock Clinic where she began her analysis with W. R. Bion. She published her first bookA Group of Juniors: A Study of Latency Children’s Play in 1951. At the end of her training, she travelled to the USA in the mid-1950s to work at the James Jackson Putnam Contributors xix

Center, where they treated what was then called ‘atypical’ psychotic children, and she began her extensive study, research and writing about psychogenic autism in what are some of the earliest publications on the psychoanalytic treatment of this condition. After returning to London, she resumed her treatment of autistic children and published her second book Autism and Childhood Psychosis in 1972, followed by three more books – Autistic States in Children (1981), Autistic Barriers in Neurotic Patients (1987) and The Protective Shell in Children and Adults (1990) – as well as numerous journal articles, trans- lated worldwide and published in the International Journal of Psychoanalysis and other peer-reviewed journals and edited volumes up until her death in 1994 at the age 81. Tustin’s many significant contributions to the development of psychoanalysis were recognised in 1984 by the British Psychoanalytical Society, which awarded her the rare status of Honorary Affiliate Member. Downloaded by [New York University] at 03:54 14 August 2016 This page intentionally left blank Downloaded by [New York University] at 03:54 14 August 2016 Introduction to the life and work of Frances Tustin

Theodore and Judith Mitrani

This introduction will begin to elaborate on the original work of Frances Tustin, her theoretical conceptualizations with regard to autistic states in children and adults, and various applications of the same. Following a succinct biographical note, I shall outline the development of Tustin’s thinking and attempt to clarify several notions that she articulated in an effort to become more precise in the psychoanalytic diagnosis, dynamic understanding, and psychoanalytic therapy of autistic states. Frances Tustin was born Frances Daisy Vickers on October 15, 1913, the only child of deeply religious Northern English parents. Father, a lay reader in the Church of England and a school teacher, was absent for a number of years during World War I when he became a prisoner of war. During that period, he lost his religious faith and, upon returning home, engaged vigorously in the application of progressive liberal teaching methods in small-town primary schools. The gulf between Tustin’s mother, a deaconess of the Church – religious, proper and somewhat phobic – and her humorous, independent-minded and restless father grew, culminating in the mother’s sudden decision to leave her husband, taking Frances away with her. Divorce was not a consideration for her, as this was offensive in the eyes of the Church. Then thirteen years old, Tustin was deeply attached to her father and the separation had a profound effect upon her. As a young woman, Tustin trained as a primary school teacher in a church- sponsored establishment. She was married briefly and divorced until, in 1946, she met and married Arnold Tustin, a witty, literate professor of electrical engineer-

Downloaded by [New York University] at 03:54 14 August 2016 ing, whose death in 1994 she survived by only ten months when she succumbed to intestinal cancer in November of that same year at the age of 81. In 1950, Tustin was introduced to the field of child psychotherapy in London. She trained at the Tavistock Clinic and qualified in 1953. It would not escape the attention of those familiar with the history of the psychoanalytic movement in London that the three decades between 1940 and 1970 were marked – along with significant professional/scientific progress – by acrimonious strife, hostility and ideological zeal between the Kleinians and the Anna Freudians, as well as between the Kleinians and the Independents. This atmosphere was particularly relevant to Tustin’s professional formation. The staff of the Tavistock Clinic xxii Theodore and Judith Mitrani

consisted of therapists and instructors from both the Kleinian and the Independent schools. However, on the whole, the training at that time was segregated along ideological lines. One of the most significant exceptions was the program of infant observation. This discipline was established by Esther Bick and John Bowlby. The former was known for her intuitive capacity and her strict adherence to the principles of Klein’s teachings, whereas the latter gained a reputation for his outstanding body of rigorous scientific work in which his ethological perspectives and his emphasis on the significance of observable behavior were paramount. Both Bick and Bowlby were known for their acute observational talents. Bick used her observations as the basis from which she drew inferences that led her to articulate formulations regarding the baby’s internal world of unconscious fantasies and objects within a Kleinian frame of reference. Tustin learned from both Bowlby and Bick, although the bulk of her training was Kleinian in nature, and she was strongly influenced by her close friends Martha Harris and Donald Meltzer. Of paramount importance in her professional and personal development was her analysis with Wilfred Bion, to whom she was originally ‘assigned’ by Bick, as the custom then dictated. Her 14-year analytic experience with Bion, his intense interest in thought formation and in the functions of the mind, permeates her work in a rather real if subtle way, perhaps due to her originality of formulation and the patient population with which she worked. The analyst Oliver Lyth (husband of the late Isabel Menzies-Lyth) once wrote Tustin (commenting on one of her papers) that she ‘seemed to have absorbed from the atmosphere of the couch what the rest of us have to learn from reading and re-reading [Bion’s] books.’ Following a year of research with autistic children and their families at the Putnam Center in Massachusetts, while her husband was teaching at MIT, Tustin worked as a child psychotherapist at Great Ormond Street Hospital between 1955 and 1964. She returned to the Tavistock, both as a researcher and as an instructor in the late 1960s and early 1970s and participated in the study group on autism headed by Donald Meltzer (Meltzer et al. 1975). However, Tustin’s grasp and understanding of the clinical research differed considerably from that of Meltzer’s group, who were attempting to refine the Downloaded by [New York University] at 03:54 14 August 2016 basic Kleinian frame of reference in order to further comprehend their findings. Thus in 1972 she published her views independently in her book Autism and Childhood Psychosis. Although she was a popular supervisor at the Tavistock, Tustin was barred from teaching core courses, apparently due to her particular position. For some Kleinians, her insistence on upholding the impact of trauma, generated in part by problematics within the pre- and post-natal environment; her attention to states in which unconscious fantasy may barely function or is foreclosed upon and obliterated; her recognition of the sensorial illusion of continuity between the mouth and the breast as a necessary and normal developmental phenomenon, not Introduction xxiii

just a defensive pathological aberration; and her conception of the dimension of sensation-dominated psychology were some of the issues that were considered anathema by mainstream Kleinian thinking at that time. On the other hand, for the ‘Independents’, her elaborations on the constructs of primitive destructiveness and primary envy, even though reframed in a context and with a significance that diverged from Klein’s, her emphasis on symbol formation, and her intensive consultations with Esther Bick, Herbert Rosenfeld, and Don Meltzer cast her in a Kleinian light. Interestingly, from the 1970s onward, Tustin felt a profound affinity with Winnicott’s contributions as well. Some of the chapters in this volume will expand upon these areas of connection with and divergence from both the Kleinian and Independent schools of thought in Great Britain. However, it may be important to note that, in 1984 – on the basis of her outstanding contributions to psychoanalysis – Tustin, who had not been formally trained as a psychoanalyst at the British Society’s London Institute, was made the third honorary affiliate member of that Society, which was originally founded by Ernst Jones in 1923.

The patient population Tustin’s clinical interest focused on the predicament of psychotic children, particularly autistic children. We shall remember that it was not until 1943 that the syndrome of childhood autism was formally articulated as a diagnostic category by Leo Kanner (1943). His conceptualization differentiated these ‘atypical’ children from others diagnosed as schizophrenic or mentally retarded. Early in her career as a therapist, Tustin – like other child workers – observed certain features in the autistic child that were unlike those of schizophrenic-like children and realized that the technique of treatment espoused by Melanie Klein (1930) was less than effective with them. This is not accurate. It was not known at the time, and remains controversial to this day, to what extent neurological dysfunction may have causally contributed to this condition. In her experience with the parents of these children, she came to appreciate the great burden that they carried in attending to their seriously ill children. In her anamnesis, Tustin also noticed an inordinate frequency of pre- and postnatal depression in the mothers of such children. This confirmed findings reported Downloaded by [New York University] at 03:54 14 August 2016 by Mahler (1969), Meltzer (1963), and Tischler (1964), to name just a few. Furthermore, in her observations of the children in the psychoanalytical clinical setting, she noted that both the schizophrenic-like children – entangled with objects and people – and the withdrawn, seemingly inaccessible autistic children appeared to be highly preoccupied with sensation-dominated activities. She provided ample descriptions of such activities in her written works. By the late 1950s, Tustin was fortunate to begin her private work with children who had been referred to her by Dr Mildred Creak – the foremost London psychiatric diagnostician specializing in childhood psychosis at the time – with whom she had worked during her time at the Great Ormond Street Hospital. xxiv Theodore and Judith Mitrani

On the grounds of the neuro-diagnostic means available at the time, Dr Creak determined that there was no detectable brain damage associated with the schizophrenic-like and autistic symptoms observed in the children she referred to Tustin for treatment. Tustin adopted the term ‘psychogenic autism’ for such children.

Observation and theory Tustin’s observations of the children in her care provided the grounds for her attempt at theoretical formulation regarding: (1) the classification of the clinical phenomena observed; (2) etiological considerations; (3) developmental models; and (4) recommendations for psychotherapy. One of her basic observations with regard to psychotic children led her to classify two large groups, distinct from each other, yet sharing a common link.

The observations She termed one group the ‘entangled or confusional’ psychotic and the other the ‘encapsulated’ or shell-type psychotic. The common link between these two groups was the inferred function of their respective behavioral and psychic maneuvers: the avoidance of the unbearable awareness of bodily separateness. Tustin used her unique communication skills in order to provide us with a detailed description of her keen observations, which evoked in her experiences that she tried to understand in a psychoanalytic way. In turn, it was this understanding that led her to discover and map a new analytic model, which further influenced her way of working. Although this process may appear as linear and graceful, the reality is much more complex and includes the influence of input from other prominent workers in the field such as Bick (1968), Meltzer (1975), Rimland (1964), and Mahler (1968).

The confusional child To return to the subject of Tustin’s physical observations, she found that one group of psychotic children manifested a strong tendency to mold themselves Downloaded by [New York University] at 03:54 14 August 2016 bodily, to get entangled with the bodies of others or with soft objects such as clothing, or bodily substances such as feces, urine, and saliva (either drooling or in bubbles). These children usually could speak; however, their language was confused – particularly in their use of pronouns – and was felt to intrude into the listener in a demanding and nonsensical way. They would sometimes maintain eye contact, albeit of a particular variety. It was obstinate in nature, yet it was also clear to the observer that their eyes looked glassy or waxy and the focus, while unclear, was elsewhere and beyond the person looked at. It was also obvious that basic perceptual and sensorial modes, such as the visual and auditory – along with the capacity for attention – were astonishingly constricted. For example, one Introduction xxv

child was said not to have noticed anything different about the play-therapy room, which had been repainted in bright colors between regular sessions (Tustin 1986a). From this Tustin inferred the child’s need and demand for unending changelessness. Of their predominant use of objects, which Tustin (1972a) came to call ‘confusional objects’, she wrote:

Confusional objects are used in ways which are peculiar to each individual child. Confusional objects are used compulsively. They blunt the child’s awareness of needing nurturing care and prevent him from recognizing that it is separate from him. Children who use confusional objects are in a twilight state of awareness all the time whether they are using the confusional object or not … (p. 128)

Tustin referred to an example presented by Mrs Pick (Tustin 1992):

From the age of 18 months, the object to which he has become attached (I feel it cannot truly be called a transitional object) has been his pillow, inside whose cover he slips one of his arms. Mother herself directly compared this to the hand inside the vest or sheet of earlier months.

Tustin commented:

Mrs Pick observed this baby boy every week from birth onward. Very early in life he showed worrying features. One of these was the fact that his tongue often got in the way of his feeding at the breast. On one occasion, when he was five months old, the observer noticed that the baby’s tongue was deep purple as it protruded from his mouth. The mother said that this occurred when he gripped it with his gums. (There was no evidence of epilepsy in the child.) (p. 131)

It seemed to Tustin that the sensations generated by this activity were meant to confuse the tongue with the nipple. That is, the tongue was used as a soft confusional object dimming the perception of the ‘not me’. Downloaded by [New York University] at 03:54 14 August 2016

The encapsulated child Pervasive perceptual constrictions appeared also to be typical of a different group of psychotic children identified by Tustin. She called them theencapsulated or shell-type children. While she realized that the confusional child is much closer to what is understood to be the schizophrenic-like child similar to most children that Klein had written about rather than those characterized in Mahler’s terms as ‘symbiotic’ psychotics, this second group was observed to manifest different and distinct behavioral patterns. xxvi Theodore and Judith Mitrani

Most of the encapsulated children were very deeply withdrawn and seemingly inaccessible. In Tustin’s view, Bettleheim’s metaphor of the ‘empty fortress’ seemed quite apposite to them. They were usually mute, exceptionally non- responsive and non-reactive, and subsequently were often misdiagnosed as deaf. They also lacked the capacity to play, as distinct from the confusional children, who demonstrated an appearance of the ability to play, albeit in a chaotic and ultimately disintegrative way. Encapsulated children were drawn to holding and possessing hard objects. They could not be said to play with these, but only to hold on to them. When these objects were removed or lost, these children exhibited signs of distress and sought replacements for them. Furthermore, the bodies and muscle tone of the encapsulated children were hard, virtually rigid and unyielding. Their physiological constitution was sturdy. As a rule, they averted their gaze from the gaze of others, and the tone of their activity was mournful and quiet while the confusional children tended to be hyperactive and chaotic. As for the particular use of hard objects by the shell-type child, Tustin gave the following examples:

At the beginning of treatment, an autistic 10-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 clear that the Dinky car was felt to have magical properties to protect him from danger. […] 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 it was as if the car was still a part of his body to keep him safe. Another autistic child called Peter […] used to bring to his sessions a large key ring 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 attempt to help them. (1981)

Downloaded by [New York University] at 03:54 14 August 2016 [Autistic objects] are used in ways which are idiosyncratic to each child. […] 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 play things. 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. […] They have no fantasy associated with them. (pp. 103–4) Introduction xxvii

Autistic shapes In addition to the predominant use of confusional and autistic objects respectively by the confusional and the encapsulated child, Tustin (1984b, 1985b, 1986a) also found that both kinds of children, as well as adults with pockets of confusion and/or encapsulation, made use of what she called ‘autistic shapes.’ She (1984, 1985/1986b) differentiated between normal shapes and autistic shapes. Of the normal shapes she wrote:

These early shapes arise from the ‘feel’ of soft bodily substances such as feces, 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. […] 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. (p. 121)

In contrast, the autistic shapes were formed when the autistic child wriggled, spun, swung, or rocked his body to make shapes from bodily substances. These shapes were repetitive and unchanging. Tustin (1986a) further clarified:

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 cooperative interplay with other people. It is also unduly suffused with crude autosensuousness. This makes the children pick up the wrong cues for ongoing psychological development. They become 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. Downloaded by [New York University] at 03:54 14 August 2016 This means that the activities of autistic children are mostly asymbolic. […] (the ‘shapes’ may be a kind of tactile hallucination). (pp. 124–5)

Diagnostic classification The aforementioned criteria for differentiation constitute selected items from a more complex list compiled by Tustin (1991: 78). The differences in the behavioral features of the two groups called for close scrutiny in the course of which she further sharpened her diagnostic basis. Tustin realized that a number of confusional xxviii Theodore and Judith Mitrani

children manifested features similar to those of the encapsulated children. Ultimately, she suggested the following two diagnostic models for childhood psychosis: ‘confusional: primary; secondary’ and ‘encapsulated: global; segmented’ (1991: 46). The primary confusional syndrome had no known precipitating psychogenic factors; the secondary confusional syndrome was seen to have developed as a reaction to physical or emotional trauma, shaking the foundations of previous development; the global type encapsulation was seen to be analogous to the Kanner autistic syndrome; while the segmented encapsulation described a constellation in which speech was echolalic, and the isolating capsule was segmented or intermittent rather than compact and continuous. Concomitantly, there was a segmentation of perception, such that an object or person – seen as a whole by an observer – was segmented in the child’s mind according to the type of sensation perceived. For example, a Dinky car would be perceived as separated into segments: a red Dinky car (for visual sensation), a hard Dinky car (for tactile sensation), and a machine-oil-smelling Dinky car (for olfactory sensation). Thus a rigid compartmentalization was created in both the object and the child’s perceptions. More detailed descriptions of the segmented child can be found both in Meltzer et al. (1975) and in Tustin (1991). Tustin writes:

Certain experiences made me suspect that such children were shell-type children in the beginning, but that further disturbances of their pathological autism caused them to react by segmentation processes. (p. 54)

She conveyed her observations, made in an assessment session with the five-year- old boy Leslie, who (she thought) had been a shell-type child prior to separation:

Mother and Leslie […] were seen together. At first Leslie went from one object to another in a somewhat aimless way, avoiding looking at me or his mother. At a certain stage, I suggested that mother might leave the room. Leslie did not watch her leave, or show any obvious emotion at her departure. However, he immediately went over to a cardboard cylinder about nine inches in length, which had a pointed red lid. He smelt the lid and then pulled it off the cylinder Downloaded by [New York University] at 03:54 14 August 2016 without looking at it. Then, with a vicious look on his face, he kicked the dismantled object around the room in an uncaring way, smelling at it every now and again but avoided looking at it. After the first touching of it to take off the lid, he avoiding touching the lid with his hands. It seemed to be a ‘smell’ object. Later, in treatment, he drew pictures which he said were of a ‘cry’ or a ‘cough’ or a ‘laugh,’ which were surrounded by a thick black penciled frame. (pp. 55 and 59)

These descriptive classifications constituted one aspect of Tustin’s conclusions. However, the heart of Tustin’s interest resided in the psychoanalytic understanding Introduction xxix

of these observations, and subsequently in the refinement of her psychotherapeutic skills.

Etiological considerations For Tustin (1985/1986), ‘The study of psychogenic autism is the study of the narrowing of perception through terror, but it is also the study of the fusing of sensation which gives the state its unbearable poignancy’ (p. 190). She conceived of childhood psychosis as a protective compensation for what Winnicott (1958: 222) termed ‘psychotic depression’. He suggested that, in response to a very early breach, a ‘primitive agony intense beyond description is suffered and immediately triggers an organization towards invulnerability’. Tustin believed that Winnicott’s conclusions coincided with what Bibring (1953) referred to as ‘primal depression’, which he delineated as a triad of exhaustion, helplessness, and depression. This triad replaces the frustration and anger of failing to bring about the satisfaction of oral needs. He proposed that:

The emphasis is not on oral frustration and subsequent oral fixation, but on the infant and little child’s shock-like experience of fixation to the feeling of helplessness. (p. 367)

However, as Winnicott (1967) reminded us:

The autistic child who traveled almost all the way to mental defect is not suffering any longer. Invulnerability has almost been reached. Suffering belongs to the parents.

Similarly, Balint (1968) coined the term ‘basic fault’ for an area of grief or mourning coinciding with Mahler’s (1961) ‘symbiotic phase’. It is interesting to note that Freud (1926) wrote about the emergence of grief in the infant who experiences the state of object loss as a permanent condition. The underlying essence of the notion of psychotic depression is the experience of a traumatic awareness of separatedness from the mother, occurring before the infant is emotionally equipped to deal with it. Consequently, this loss is experi- Downloaded by [New York University] at 03:54 14 August 2016 enced in bodily terms as the loss of a cluster of sensations along with a bodily part. Typically, the bodily part is felt to be the mouth. Tustin illustrates this as she writes about her patient John.

On one occasion when his autism was becoming modified and he was beginning to speak, 4-year-old John saw his mother’s friend feeding her baby at the breast. This made a great impression on him and stimulated him to tell me about what he referred to as ‘the black hole with the nasty prick’. This was John’s attempt to put into words an experience he had in early infancy, when he had no words to conceptualize it. It was not exactly a metaphor. xxx Theodore and Judith Mitrani

This picturesque phrase picked up the essential essence of the original experience, for ‘holes’ are something we have an inbuilt reaction to avoid, and ‘pricks’ are something that we flinch from. John conveyed to me that this ‘black hole’ experience was the result of his finding, as a very young baby, that the nipple of the breast, or teat of the bottle, the ‘button’ as he called it, was not part of his tongue or his mouth, but was separate from it and thus was not under his control. He felt that it had broken off and been lost in a traumatic way, turning the mouth into ‘a black hole with a nasty prick’. (Tustin 1990: 78–9)

The confusional psychotic child, who is ‘closer to flesh and blood’ (Tustin 1991: 66), senses this separateness as an incurable open wound in the body, which he tries forcefully to deny by attempts at entangling himself with, intruding himself into, or dispersing himself around available objects or persons. In short, he becomes actively confused as a defense against the sensations of bodily loss. In contrast, the shell type or encapsulated child withdraws from objects in such a massive way as to lose virtually any sense of being alive or a sense of others’ aliveness. He lives in a two-dimensional niverse of inanimate objects where surfaces and their textures – especially the sensation of hardness – matter most. In this way, the ‘black hole with the nasty prick’ – described in retrospect by John, once he began to speak – and the terror and impotent rage born of a ‘premature awareness of bodily separatedness’ may be covered over. Tustin equated the dread of the ‘black hole’ with the horror of falling forever in a desolate and infinite space. This is one of the main psychotic anxieties or agonies described by Winnicott (1974). The autistic defenses – obliterating perception, freezing up feeling, paralyzing thought, blotting out and amputating fantasy, and avoiding communication by fixing attention onto sensations created by holding onto hard objects – are aimed at diverting awareness away from sensing the unthinkable dread. She writes:

My own clinical work has convinced me that both freezing and immobiliza- tion (playing possum) are psycho-reflex reactions that are part of our biological heritage, having been triggered off by traumatic awareness of bodily separateness from the mother, in a nursing situation in which an infant, in an Downloaded by [New York University] at 03:54 14 August 2016 immature state of neuro-mental organization, was not sufficiently protected against the terror aroused by existential threats, the mother’s state of mind and the emotional climate of the family normally being significant in that protection. As the result of such unconceptualized traumas in early infancy, protections that were so exaggerated and warped as to be aberrant have been set in train. These give autism its peculiar character. (1990a: 95)

It is important to emphasize that Tustin identifies the etiological trigger factor as the premature awareness of bodily separateness. This is quite different to the Introduction xxxi

obvious case of actual physical separation occurring between mother and infant, even though such events are able to trigger either encapsulated or confusional trends. Should the catastrophic awareness occur when the infant is as yet unintegrated – with only a dim sense of tri-dimensionality and ‘flickering states’ (Tustin) of recognition of the gap between ‘me’ and ‘not-me’ (Winnicott), or perhaps before the establishment of the ‘psychic skin’ (Bick) that holds the self together – the reaction will tend toward encapsulation. In this connection, I wish to point out the importance of a particularly fundamental process, which Bick (1968) called the ‘second-skin’ phenomenon. The ‘second-skin’ is a construct that refers to a cluster of psychophysiological reactions in response to overwhelming dread. It has the function of constricting attention and shutting-off awareness, rigidifying both mental activity and muscle tone – all in the service of generating a scaffolding which functions to provide numbness and invulnerability. This isn’t really how Bick defined it. Of her patient John, Tustin (1986a) writes:

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. The 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 part of his body, which ensures everlasting continuity […] such patients feel ‘paper thin’. They do not differentiate between insides and outsides, and live in terms of surfaces and superficial appearances. (p. 301)

Encapsulation may occur either prior to a resilient and healthy cluster of ‘psychic envelopes’ (Anzieu 1985), or subsequent to a violent and devastating rupture of the psychic skin, when both internal and environmental resources for repair are insufficient. Should a similar experience take place at a time when the infant is better integrated, the reaction may be one of disintegration, confusion, and massive states of projective identification or of segmented encapsulation.

A developmental model Downloaded by [New York University] at 03:54 14 August 2016 In Tustin’s seminal paper on ‘Psychological Birth and Psychological Catastrophe’ (in Grotstein 1981a), one may clearly detect not only the profound influence of both Bion and Winnicott upon her clinical thinking, but also the part that her own vigorous originality played in shaping her formulations as well. In that paper, Tustin attempted to sort out the factors that contribute to either a normal process of psychological birth or to catastrophe. She refers to Bion’s metaphor about the state of mind following an early catastrophe as one of a city in ruins due to a cataclysmic event: one in which elements from different layers and locations seem to be all jumbled up together. Tustin articulates a developmental model, at the foundation of which sensation is considered to be the most elemental and xxxii Theodore and Judith Mitrani

important factor in the process of integration. She noted that soft sensations are generally pleasurable, while hard sensations are felt to be unpleasurable. Gradually, the soft sensations become associated with taking-in and receptivity, while the hard sensations become associated with entering and thrusting: a dawning sense of tri-dimensionality. Softness is further associated with the female and hardness with the male. When these earliest integrations between the sensations of hard and soft occur – the hard nipple and tongue working together with the soft lips, the oral cavity and the breast, to produce a sensation of satisfy- ing fullness with the milk – ‘a new way of functioning is born, that of firm adapt- able resilience and toughness’ (Tustin, 1981: 100). Such sensation experiences, along with the indispensable neurophysiological developments, set the stage for the processing of reality and the emergence of the psychological dimension. That is, bodily sensations are elaborated in the dimension of imagination or unconscious fantasy. Percepts and concepts begin to emerge here as well. Clearly the input of the primary caretakers has a decisive impact upon this process as much as the infant’s innate capacities. Tustin came to compose this particular developmental model based upon her experience with children in whom this unfolding growth had gone severely awry. She called these aborted processes of mental development ‘psychological catastrophes’, borrowing the notion from Bion (1962a). Like Winnicott, she suggested that a complex growth process needs to take place in order for the infant to reach psychosomatic integration, psychological functioning in phantasy, a sense of tri- dimensionality, a sense that both the hard and soft sensations reside within the infant and yet both can also come from outside. Subsequently, a sense of an inside and an outside develops, allowing for the operation of normal projective identification. At the same time, while Tustin’s emphasis on ‘sensation’ as the archaic element at the foundation of the mind and ultimately of the capacity for thinking resonates with Bion’s (1962a) ‘Theory of Thinking’, her model is an expression of her own ingenuity, honed by her particular clinical experience. In its elaboration, it constitutes a new paradigm of mind. How? Now, as mentioned above, this model is one of optimal development. However, serious pitfalls may be encountered, which impede such benign development and the natural growth-producing sensation-experiences mutate into autistic trends. Good-enough holding (Winnicott 1958c) and containing (Bion 1962a) capacities Downloaded by [New York University] at 03:54 14 August 2016 of the mother are necessary for a successful early integrative process. Should the mother’s resourcefulness be inadequate, relative to the needs of a given infant, the latter may feel left all alone to contend with the overflow of excitement, frustration, and other experiences – however rudimentary – of being alive. What may potentially be felt as the ecstasy of at-one-ment may rapidly degenerate into a devastatingly harsh sense of twoness that is prematurely imposed. Likewise, when frustration is left unresponded to, a state of tantrum sharply accentuates undue terror of helplessness and aloneness. Here the stage is set for the employment of autistic maneuvers of either the entangling or the encapsulating variety. This makes it sound as though everything stemmed from defective mothering, Introduction xxxiii

whereas Tustin frequently pointed out that children with autism are very difficult to rear. Tustin (1994c) concluded, in her final paper (reprinted in this volume as Chapter 1), that the term ‘autism’ needs to be reserved for pathological states. It is never a normal developmental stage. Both Tustin and Tischler (1979) noted that confusional tendencies in the mother may often tilt the choice of defensive maneuvers toward the confusional side. Schizoid, depressed, and withdrawn tendencies in the mother or in both parents, or seriously sustained preoccupation, worry and anxiety, can tilt it toward encapsulation and the formation of a protective shell. Another essential factor, which may facilitate the onset of these early reactions, is the infant’s sensitivity and capacity to endure frustration.

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 [a variety of interfering] factors. (Tustin 1985/1986: 98)

Tustin also stressed:

Different underlying causes can give the same presenting picture. In some cases, there has been undue parental pressure and insufficient healthy maternal preoccupation. In others the child was unduly vulnerable even to normal pressures; maternal preoccupation, which would have been adequate for a normal infant, was not adequate for him. (1981/1992: 129)

For Tustin (1981), the essential process of ‘rootedness’ (p. 33) has failed to evolve in these children. This process might be related to (or perhaps is the precursor for) what Bowlby referred to as ‘bonding’. Tustin found that, at the center of the autistic universe, was what her little patient John called the ‘black hole’ in which he had been experientially encased. Based on her experiences with John and others, she traced the process of the formation of this black hole (1991: Downloaded by [New York University] at 03:54 14 August 2016 32). She extrapolated that, on its most primitive level, the failure of a sense of cooperation between nipple and mouth deprive the infant of the elemental foundation for a reliable sense of rootedness and the growth of identity. Indeed what is generated in its place is, in large part, a sense of nothingness and of falling endlessly, spilling away, and dissipating. The sense of failed cooperation between nipple and mouth is also accompanied by a sharp and premature awareness of ‘twoness’ and bodily separatedness felt as a ‘nasty prick’ or painful, malevolent puncture of the nascent psychic skin. The anguish, rage, terror, panic, and despair of ceasing to be find no leeway and no avenue of expression due to both the infant’s immaturity and the mother’s limited xxxiv Theodore and Judith Mitrani

or damaged capacity to suffer and to be mindful of such states. Subsequently, these tempestuous emotions of early destructiveness constitute unbearable dreads that implode in the infant, creating a black hole. This black hole exercises an inordinate magnetic pull, a chronic sense of a lack of safety in dealing with the ‘not-me’. Furthermore, the psychological birth of the ‘me’ is continuously stulti- fied by the infant’s attempts to protect itself. This protection – the autistic encapsulation – grows out of the repetitive compulsive use of autistic maneuvers. The encapsulation or shell is so primitive in nature that Tustin preferred to consider it a ‘psychophysical reaction, rather than a defense mechanism’ (1990a: 154). It would seem that the more familiar symptom of psychosis – the bizarre, driven, idiosyncratic creation of delusional universes – is in part the expression of a mind that recruits its capacity for imaginative functioning into a contorted defensive structure, which is only obliquely communicative. It is here that Bion’s (1962a) conjecture – that the sense of no presence of contact violently erupts as a ‘no-thing’ – is applicable. On this level, he states that ‘all needed objects are bad objects because they tanta- lize’ (p. 84) and the need then turns into the need to evacuate these bad objects. However, encapsulation is an even more withdrawn state which ‘insulates the child against the cold, hard, bitter, rough ‘not-me’ (Tustin 1981/1992: 171). The deadness of the autistic shell is also a protection against archaic dreads. Tustin clarifies:

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 tooth and claw’, and the hard autistic objects seem to be extensions of nails and teeth. (1981/1992: 122)

The core of the autistic universe, with its dominant sense of void and unbounded gap, is much closer to the ‘white psychosis’ described by André Green, although in the latter, imagination is not hypertrophied or disfigured, but instead is virtually stunted and paralyzed.

Downloaded by [New York University] at 03:54 14 August 2016 Recommendations for treatment Tustin’s psychoanalytic understanding of the fundamental predicament of autistic encapsulation and its nature lead to certain recommendations for treatment. First and foremost, she emphasized the importance of the therapeutic frame. This must be firm, not mechanically rigid. In this she joined other contributors who discovered that the need for and the significance of a reliable, stable setting in time and space – held firm by the analyst – increases with the severity of the affliction. Thus she would insist on a formal opening and ending of the session through the means of greetings, in order to explicitly mark the boundaries and in order not to collude with the tendency of these patients to ‘tiptoe’ seamlessly in and out of the Introduction xxxv

therapeutic encounter. In her discussion of Thomas, a case she supervised, Tustin states:

Underneath their passive exteriors, these children are little tyrants. They are like a ‘cock on a midden’, being very controlling and dominating. When Thomas broke down the usual arrangements and bounded past the therapist into the therapy room, he ignored her presence and her arrangements. Helping Thomas to wait established the therapist’s existence as a person who could not be nullified. He could not tamper with her arrangements. She was not canceled out. […] this had striking results. Thomas began to play. He could now work over with his therapist those infantile situations that had abrupted his emotional and cognitive development. (1990a: 116)

Once they reached the stage of using play materials, she actively expected the children to clean up whatever materials they used prior to the end of the session. Tustin found this practice – which differs from that usually applied by child workers trained in the Kleinian/object relations tradition – to be an important part of the formal behavioral setting that contributed to the ‘rhythm of safety’ (1985b/1986) whose greater intricacies unfold in the therapeutic and interpretive stance. She would also physically restrain a child, not only when his compulsive behavior threatened harm to himself, herself, or to the room, but also when the child engaged in stereotypy or when he would erupt in tantrum. However, Tustin insisted that any physical intervention must be accompanied by an interpretive statement addressing the function and/or the meaning of such behaviors. For example she writes:

Active responses may take the form of holding the child’s hands when he is flapping them or using them for his idiosyncratic stereotypes. As we do this […] we might say ‘I know you’re so excited – or so frightened – or so upset – that it is spilling into your hands. But I am holding them, and the upset – the overflow – is going into me. I can hold it for you. There’s no need to flap – there’s no need to rub your hands together […] Tustin is holding the upset.’ I have found that repeating a simple phrase over and over again, such as ‘Tustin is holding the upset’ or ‘Tustin is holding the flap’ or ‘Tustin is hold- Downloaded by [New York University] at 03:54 14 August 2016 ing you together’ is often very helpful to these children. […] Such behavior is not idle reassurance which fobs off the child and his terrors. It is genuine and caring support for a child who is overwhelmed by primitive impulsions because he has no apparatus to process them. We contain them for him. (Tustin 1981/1992: 158–9)

Analytic workers who have therapeutic experience only with adult patients often regard such interventions as ‘non-analytic’, while child workers realize that in order for the therapist to limit himself to verbal interpretations alone, a child must be of a certain age and must have attained a certain level of psychic development. xxxvi Theodore and Judith Mitrani

However, in the case of one adult, Tustin (1984c/1986) did not hesitate to instruct her patient to cease her clandestine activity of biting the insides of her cheeks and sucking her tongue when she discovered that this autosensual activity created a protective ‘second skin’, which distracted the patient and obstructed potential emotional contact with her own mind as well as her capacity for true relatedness with the therapist. Nevertheless, Tustin found her main working tool to be the analytic interpretation.

For example, at a certain stage in the process of psychotherapy an autistic boy I once treated as the end of the session grew near, in order to feel we were one in the same and that we were not separate from each other, would imitate the way I was sitting. He would place his legs as my legs were placed, and his arms as my arms were. As I interpreted this in relation to the coming end of the session, he began to accept the fact that we were separate and different, but not disastrously blown apart. (Tustin 1990a: 67)

However, her interpretations – when aimed at the encapsulated self – were informed by her conviction that it is the very concrete sensation-dominated experience that needs to be addressed, including the various ‘unthinkable dreads’ – felt on the bodily level – and the creation and/or the use of both those hard autistic objects and soft autistic shapes that such dreads precipitate. In this manner, she distinguished the analytic approach to the treatment of autistic states from the approach commonly used, especially by Kleinians, in cases of non- encapsulated psychosis with its intricate defensive organization characterized by intense splitting and intrusive projective identification. Parenthetically, it may be argued that even the most active and florid psychosis may itself enfold a core of autism and may render this core virtually undetectable and unreachable so long as confusional activities are engaged in. In a different connection, Tustin (1990c) states:

In treating autistic children, I have found the therapist’s state of mind to be of prime importance. […] The therapist’s undivided care and attention is of the utmost importance in work with these children who, behind their pro- Downloaded by [New York University] at 03:54 14 August 2016 tective shell, are very vulnerable and hypersensitive. The therapist’s undivided care and attention is a kind of psychic ambiance that surrounds these children and can gradually give them the confidence that this reciprocal intangible protection can replace the sensation dominated illusion of tangible encapsulation as if by a shell. (pp. 63, 64)

In Tustin’s writings we can easily recognize that, as soon as the patient – whether child or adult – begins to emerge from its shell of autism with a budding sense of tri-dimensionality and the rudiments of symbol formation, she is completely at Introduction xxxvii

home interpreting issues of omnipotence, triumph over the analyst, and projective identification. We can find examples of her versatility – that agile yet thoughtful and disciplined capacity to address varying dimensions of the patient’s material in her narrative of the analysis with Peter (Tustin 1986b). She reflects:

When these 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. (p. 135)

With regard to Peter she writes:

He was now talking, though somewhat laconically, so that 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. […] 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 ‘collapsed’ being the child’s way of experiencing the psychotic depression which is at the center 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 […] he proceeded to fasten other toy animals onto the string and to haul these up too. But there was a difference in the way he dealt with these animals. For one thing, as he put each animal on the string he said, ‘and now I will put this shape on 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.’ […] 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. I suggested that the top one was his head and the bottom one was his bottom. I also suggested that the locked drawers in the middle part might be his tummy, to which he replied firmly and dismissively, Downloaded by [New York University] at 03:54 14 August 2016 ‘That part is missed out.’ […] 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. (pp. 136–7)

It is a rather helpful feature of Tustin’s writings that, in the tradition of British analytic authors, she provides abundant clinical accounts and vignettes, which shed much light on her way of working. For example, it becomes clear that she is consistent in her lack of sentimentality, a feature central to her analysis of psychotic children. A most helpful attitude in any solid therapeutic process, this characteristic assumes a special significance in the work with autistic states, given xxxviii Theodore and Judith Mitrani

the inordinate degree of despair and helplessness that their condition and conduct provokes in the therapist.

Therapeutic work with autistic children needs to be unsentimental and down to earth. Some psychotherapists are so touched by the tragic state of these children that they are over-indulgent towards them. This is the worst thing that they can do. In spite of being able to do very little, these children feel very powerful. (Tustin 1986b: 117)

Applications The value inherent in Tustin’s legacy was most appreciated in England by child workers, while some British analysts, mainly those working only with adult patients, have been slow to find the usefulness of her teachings and others, more conservative in nature, have disregarded her work altogether. This is certainly not the case in Asia, Western Europe, and South America, where the relevance of her findings to the treatment of learning disabilities, personality disorders, psychotic phenomena, eating disorders, substance abuse, medical trauma, and an array of primitive states in statu nascendi, both in adults and children, has been confirmed and further elaborated and extended. One special aspect of the growing research inspired by Tustin’s work has to do with the protective nature of the autistic capsule in the face of massive environmental assaults – for example, those seen in survivors of the Holocaust and their descendants. This phenomenon differs from the etiology of problematic early integrations, which Tustin found in the children she treated.

Conclusion In conclusion, I will recapitulate the essential points addressed in this introduction. Diagnostically, Tustin delineated three main psychotic groupings – the encapsulated, the segmented, and the confusional. Etiologically, she fully recognized that neurophysiological dysfunction may contribute materially to a child’s vulnerability and the constriction in his capacity to fully avail himself of the Downloaded by [New York University] at 03:54 14 August 2016 mother’s ministrations. At the same time, she emphasized the role of the mother’s reduced emotional and mental availability – affecting either her ‘holding’ or ‘containing’ capacities – as a contributing factor in the emergence of the infant’s tendency to resort to encapsulation in a deadened and deadening shell. Tustin also considered intrauterine impingements – including maternal biochemical, chronic muscular tension, and psychic states – as active contributors to fetal and later infantile withdrawal. These factors may lead to a premature awareness of twoness, which in turn may stultify further development of the mind. Additionally, she clarified that the ‘black hole’ is a bottomless state of desolation and meaninglessness resulting from unmitigated implosions of infantile aggression in response Introduction xxxix

to sensed threats to survival, as well as an empty void where the mindful presence of the mother should have been. The protective barrier or shell, constructed through the rigidified use of hard impenetrable autistic objects and soft soothing autistic shapes, is devised to block out awareness and experience of the ‘black hole’ of bodily separateness and the reality of the impinging ‘not-me’. In terms of dimensionality, the encapsulated individual exists in a two- dimensional and inanimate world. By adhering to unchanging surfaces of things, these children produce for themselves the elemental sense impressions of safety. Such sensations are unaccompanied by what we call phantasy, which remains paralyzed in these individuals. Finally, therapy with autistic states relies on the maintenance of a firm and resilient frame. At times it may include physical interventions, but these are always accompanied by interpretations aimed at the sensual/concrete level, and are also drawn from the therapist’s inner responses to the patient, as elaborated by a capacity for reverie and containment. This overview of Tustin’s teachings will perhaps serve the reader by providing a background to the numerous theoretical extensions and expansions of Tustin’s work, as well as for the extensive clinical offerings that are presented in nearly all of the chapters included in this volume. Finally, I wish to underscore the fact that, as a highly literate and well-read individual, Tustin frequently quoted poetry to get her point across. I believe the following lines from T. S. Elliot (1898), to which she referred in her last book (1990a: 112), aptly describe the world that she was moved to enter in her striving to bring her patients to life:

Descend lower, descend only Into the world of perpetual solitude … Into darkness, deprivation And destitution of all property, Desiccation of the world of sense, Evacuation of the world of fancy, Downloaded by [New York University] at 03:54 14 August 2016 Inoperacy of the world of spirit.

The reader of this collection will most certainly appreciate the ways in which Tustin’s tradition has been carried forward by each of the authors who have made contributions to Frances Tustin Today. This page intentionally left blank Downloaded by [New York University] at 03:54 14 August 2016 Part I Prenatality through latency Downloaded by [New York University] at 03:54 14 August 2016 This page intentionally left blank Downloaded by [New York University] at 03:54 14 August 2016 Chapter 1 The perpetuation of an error1

Frances Tustin

This paper is an attempt to sort out my ideas about autism before my professional life comes to an end. It is fitting that I should do this with the Association of Child Psychotherapists because, as you will see, I have been very helped in my thinking by child psychotherapy colleagues of various theoretical persuasions. I should like to think about an error made by many psychoanalytic therapists (including myself), to which I drew attention in a paper published in the International Journal of Psycho-Analysis as recently as 1991. In that paper I pointed out that observational studies of babies by workers from many countries – such as Colwyn Trevarthen (1979) in Scotland; Daniel Stern (1983, 1985) in the United States; Miller, the Rustins and Shuttleworth in England (1989); Piontelli (1992) in Italy; Perez-Sanchez (1990) in Spain – had shown conclusively that there is not a normal infantile stage of primary autism to which the pathology of childhood autism could be a regression. This has been the mainstream hypothesis concerning the aetiology of childhood autism to which many psychoanalytic therapists have subscribed, especially in the United States and in Europe. This flawed hypothesis, based on faulty premises, has been like an invasive virus in that it has permeated and distorted clinical and theoretical formulations. It has perpetuated these distortions and obstructed communication between psychodynamic workers with autistic children. It has also obstructed communication with our Jungian colleagues, for example with Dr Michael Fordham, whose model is of a ‘primary self’ that innately unfolds Downloaded by [New York University] at 03:54 14 August 2016 (or not, as in autism) to reach out and take in the environment. In this paper, I want to think about why so many of us have made this mistake, and also to discuss the theoretical and clinical adjustments necessitated by its modification. The question may be asked why such an issue is important. I would suggest that it is important because it affects our basic assumptions about a serious disorder. Also, as is always the case when an error is detected, useful lessons can be learned from its revision. In this paper I want to think about why this error has been perpetrated, and about what lessons can be learned from modifying it. Its origins are deep in history and fraught with prejudice. Let me outline this history. In doing this, I am indebted to information in a letter from an American psychoanalyst, 4 Frances Tustin

Dr Gillette, which was published in The Journal of the American Psychoanalytic Association as recently as 8 January 1992.

History of the error In this letter, Dr Gillette suggested that the hypothesis of childhood autism being a regression to a stage of normal primary autism had been so acceptable to many psychoanalysts because it had seemed to be consonant with certain statements made by Freud. One of these was that primary narcissism was a stage that followed autoerotism prior to anaclitic object choice (Freud 1914b). Thus autism was seen as a stage which preceded primary narcissism which was also seen as a state of non-object relatedness. Another of Freud’s statements that was often quoted in this connection went as follows:

A neat example of a psychical system, shut off from the stimuli of the external world, and able to satisfy even its nutritional requirements autistically … is afforded by a bird’s egg with its food supply enclosed in its shell. (Freud 1911; italics added)

Victoria Hamilton has related this to Margaret Mahler’s formulations. She writes:

Mahler’s stress on [what she had called] the infant’s ‘inborn unresponsiveness’ … leads her to expand on Freud’s fiction of the bird’s egg so that it permeates her whole conception of development. Her scheme is full of egg- like metaphors such as ‘hatching’, ‘cracking’ and ‘autistic shells’. (1982: 37)

Hamilton sees clearly that Mahler had been influenced by Freud’s statement. Metaphors that are appropriate for a description of the pathology of autism have been misapplied to normal infantile development. This has affected ideas about early infantile development and made it difficult for Mahlerians to communicate with those psychoanalytic therapists who did not subscribe to Mahler’s classical Freudian hypothesis. In connection with this Dr Gillette cites Milton Klein’s 1981 paper titled ‘On Mahler’s Autistic and Symbiotic Phases’, in which Milton Klein relates Downloaded by [New York University] at 03:54 14 August 2016 Mahler’s work to Freud. Dr Gillette quotes as follows from Milton Klein’s paper:

The autistic and symbiotic phases rest on a cornerstone of Freudian econom- ics, namely that stimuli are inherently irritating … Mahler’s metaphorical portrait of the normal infant existing in an autistic ‘shell’ or autistic ‘orbit’ fits well with Freudian principles. (Gillette 1992: 85)

Gillette says that Milton Klein saw Mahler’s theory as being ‘representative and congruent with Freudian theory’ (p. 93). He tells us that Milton Klein thought that The perpetuation of an error 5

this explained ‘why it had become the reigning orthodoxy for so long’. Dr Gillette doubts this ‘reigning orthodoxy’ and points to what he calls a neglect in the major journals of the work of Daniel Stern (1985) and others refuting Mahler and Furer’s (1968) dual unity hypothesis. Gillette instances a long history of prejudice in the United States with regard to this matter, and cites as an example the fact that ‘Peterfreund’s (1978) challenge to traditional dogma’ (that is, the ‘dual unity’ hypothesis of Mahler) ‘in a major journal was not followed by any published debate’. He goes on to instance that what he calls ‘Silverman’s (1981) brilliant and powerful empirical support for Peterfreund’s critique … was rejected by several traditional Freudian journals before it finally saw the light of day in an edited volume’. He was surprised about this because, in his view, Stern’s (1983, 1985) challenge to Mahler’s dual unity concept was ‘very persuasive’ (1985: 160). (Eventually, Margaret Mahler also found Stern’s challenge ‘very persuasive’, so that in her eighties, with scientific integrity, in a lecture delivered in Paris just before she died, she renounced the concept of normal primary autism as a phase in early infancy.) Dr Gillette (1992) concluded his letter by saying that ‘the resistance to discussing new ideas that conflict with what are believed to be Freud’s views is a significant obstacle to scientific progress in psychoanalysis’. In spite of our gratitude to Freud, without whose work we would not exist, a blind unquestioning loyalty to him can be an obstacle. With regard to the aetiology of non-brain- damaged childhood autism, such adherence has perpetuated an error. One lesson that we can learn from this error is that our loyalty should be to understanding rather than to personalities. The cult of personality is rampant in psychoanalysis. One reason for this is that our work is so anxiety-provoking that we feel the need to cling tenaciously to those people who have shed light on a dark scene. Naturally, we are grateful to them, but this can lead to prejudice and sterile controversy. Our thinking will get ‘stuck’. However, there is another reason that caused some of us to accept the erroneous view that the pathology of autistic children had stemmed from a regression to a normal phase of perpetuated autistic ‘at-oneness’ with the mother that was absolute and constant. This was the type of clinical material that we encounter in deep psychotherapy with such children. Let me now present the kind of clinical material that led me to the erroneous Downloaded by [New York University] at 03:54 14 August 2016 conclusion that there was a stage of normal autism in early infancy. This material also demonstrates particularly clearly a traumatic situation that is crucial in the precipitation of non-brain-damaged childhood autism. It is the crux of that precipitation.

Clinical material This material was presented in Autism and Childhood Psychosis (1972a; USA 1973) and in a later book, Autistic Barriers in Neurotic Patients (1986a). I must ask you to forgive me for drawing it to your attention again. I do so because it has played an important part in my thinking about autism. I would like to draw your 6 Frances Tustin

attention to sessions with an autistic boy whom I called John. John was 3 years 7 months when he first came into treatment. He did not speak, but his mother told me of nine words that he understood. These were ‘John, mummy, daddy, Nina (his sister), pee-pee, baby, potty, spin, spinning’. However, I soon became aware that there were more words than these that he understood. (Psychotherapy with these children is showing us that we have tended to underestimate how much they understand. This is being confirmed by a recent investigative technique being used with autistic children called ‘facilitated communication’.) John had all the characteristics of Kanner-type autism. At first he came once a week, then increased to three times and finally came five times a week. In the presented sessions he was coming five times a week and was five years old. He had begun to say a few words of which ‘gone’ and ‘broken’ were new words that seemed very significant for him. Janet Andersen (1992) also found this with her autistic child patient and I have found it to be the case with other autistic children I have treated since John. The material I want to present begins with session 130. John was now talking. The session took place in December prior to the Christmas holiday. There had been changes in the routine of bringing John due to his father being away from home. On the day of the session I am reporting, his father, having returned home, brought him. As they came up to the front door, the father nearly missed his foot- ing on the front steps. During the session John seemed to be trying to keep his father alive by jumping up and down on the couch saying, ‘Daddy gone! Daddy mended!’ At the end of the session when his mother, not his father, was waiting for him, he screamed, ‘Daddy gone! Daddy broken!’ Following this incident it was reported to me that he had a nocturnal screaming fit in which he said such things as, ‘I don’t want it! Fell down! Button broken! Don’t let it bite! Don’t let it bump!’ Following this, just before the Christmas holidays, some sessions occurred that were very important for my understanding of John. They began with session 140 in which John came into the consulting room and said in tones of great astonishment, ‘The red button grows on the breast.’ I had never used the phrase ‘red button’, nor had I used the word ‘breast’. (As I am a Kleinian you will find this very surprising, but this was my first autistic child patient and I had decided not to impose a theoretical scheme upon him, and to see what words he used himself.) After this session I talked to his mother and she told me that John had seen a Downloaded by [New York University] at 03:54 14 August 2016 friend of hers feeding her baby at the breast and he had seemed very fascinated by it. It seems to me that this incident triggered off a whole series of communications that made me aware of the traumatic experiences John felt he had suffered as an infant. Following his astonished remark, I asked him in a matter-of-fact way what he had thought about the ‘red button’. He pointed to his mouth saying ‘Red button here!’ I was intrigued and surprised. There is more about this to come as John depicted the infantile traumatic situations for me in a sort of dramatic re-enactment. There was a strong feeling that he wanted me to understand something that had been very important to him. The perpetuation of an error 7

In session 153, after the Christmas holidays, John carefully arranged four pencil crayons in the form of a cross and said, ‘Breast!’ Touching his mouth he said ‘Button in the middle!’ (I commented that baby John seemed to want to make 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, saying, ‘Make a bigger breast! Make a bigger breast!’ (I said that baby John seemed to want to have a bigger breast than actually existed.) At this, he angrily knocked all the pencils so that they spread over the table in a higgledy-piggledy fashion. He said, ‘Broken breast!’ (I said baby John was very cross that he couldn’t have a breast as big as he wanted.) He said, ‘I fix it! I fix it! Hole gone! Button on! Hole gone! Button on!’ (I said he seemed to want to have a breast that 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. (I interpreted how cross he felt when he couldn’t have a breast that would be as big as he wanted it to be.) He said ‘Broken’ again. Following this he went to the umbrella stand and put his hand into the glove cavity that is in dark shadow. He shuddered and said, ‘No good breast. Button gone!’ (I interpreted that his angry attacks on a breast that would not be as big as he wanted it to be made him feel that he had a ‘no good breast’ with a hole instead of a button.) He went to his box and fetched a piece of dirty grey cardboard and the crocodile. He put them on top of the box whose lid he had banged and, pointing to the Sellotape around the edge of the cardboard, he 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’ that was no comfort to him when he was on his own.) In other reports on John, I have given the following summary of occurrences in the period that followed:

Now that the infantile transference was well established and the anxieties about the ‘broken breast’ were contained in the analysis, his behaviour outside showed great improvement. He was eager to come to analysis and Downloaded by [New York University] at 03:54 14 August 2016 made good progress in spite of family illnesses, 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 father.

However, I go on to say:

An unfortunate break now occurred in the ‘holding situation’. 8 Frances Tustin

This brings us to session 194. I had shown him by means of a diagram the day he would come back to see me after the two-week Easter holiday. Family circumstances made it impossible for father to bring him back until one week later. In addition, he had been left with the grandparents for one week. When he came back I was appalled. He seemed traumatised 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 Johnny 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 one after he had been worried about his father’s safety: ‘I don’t want it! Fell down! Button broken! Don’t let it bite! Don’t let it bump!’ The hallucinated birds were a great source of terror because they threatened to peck him. However, he gradually began to bring the infantile anxieties back into the analysis. I now want to present session 360 in which all his terrors came into full expression. In this session he again used coloured pencils arranged to make a ‘breast’. (This was the first time he had done this since session 153, eight months earlier, that is before the unfortunate separation experience.) He pointed to the carefully arranged pencils and said ‘breast’. Then touching his mouth, he said ‘Button in the middle’. Then he stood a pencil in the middle and said ‘Rocket’. He called the whole arrangement a ‘firework breast’. (This linked in my mind with a drawing he had done in an earlier session of a dome-shaped object with brown and red ‘stinkers’ (his word for faeces) coming out of it that he afterwards called ‘fire- works’. This had been drawn after a tantrum when I wouldn’t let him use my hand as if it were his own.) In the session under discussion concerned with the ‘firework breast’ made out of pencils, he held his mouth as if it hurt, and said, ‘Prick in my mouth! 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 thought it might not be. We now come to session 367 which carries our understanding of his terrors still further. John was in a screaming tantrum as I opened the front door because Downloaded by [New York University] at 03:54 14 August 2016 he had fallen and bumped his head. There was no sign of damage, but he seemed panic-stricken as well as enraged. When he stopped crying I took him to the therapy room. Without taking anything out of the box of toys, he went to the table to talk to me. He said, ‘Red button gone! It fell with a bump!’ He 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 telling me about his fears when he fell down just now.) Touching his own mouth he said, ‘Nina [his sister] has got a black hole. She had a prick in her mouth. Button broken! Nasty black hole!’ (In my notes I say, ‘I should have interpreted here that he The perpetuation of an error 9

was getting rid of the nasty experiences he’d just told me about by attributing them to Nina, but I birked it’, that is I failed to take up the beginning of projective identification.) He then took the red plastic tractor, which was a toy he had attacked relentlessly. He touched the plastic axle which was not in reality sharp. However, as he touched it, he gave a huge shudder and said, ‘Nasty hard tractor, it pricks.’ He spat, as though spitting out something that was repugnant, that is projection had begun in a quite concrete way. He then screwed himself up and screamed loudly. (Here, I reproached myself for not having attempted earlier to put his projective identification with Nina into words, and so possibly sparing him from having to express it in violent action.) In his screaming he said he was pushing away flying beaks. I was afraid that he would fall off his chair so I took him on my knee and talked to him through his shrieks. (I talked to him about his feeling that the ‘red button’ was part of his mouth and how upset he felt when he found that this was not so. He felt he had a ‘nasty prick’ and a ‘black hole’ instead of the nice ‘red button’. He felt he spat nasty things into Nina whom he felt had taken the ‘red button’ 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 that showed that, on the basis of a similarity of contour, he had equated the flying birds with mouths.) I went on to say that without the button he didn’t feel safe and felt that the flying mouths could hurt him. He was afraid that he might lose his head or his penis as he felt that he had lost the button. My notes tell me that, after this, John was afraid of certain objects in the therapy room; one was the dark glove cavity I mentioned earlier, another was a penis-like pipe near the ceiling, the other was the ‘dirty water bucket’. (I had no sink in the room and the ‘dirty water bucket’ was where we emptied the dirty water after he had used it.) I go on to say that 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. Treatment came to an end when John was aged 6 years 5 months. In a rounda- bout way I’ve heard that he went as a day-boy to a well-known public day school and has done well at university. He is very musical.

Downloaded by [New York University] at 03:54 14 August 2016 Clinical discussion I was very supported in the treatment of John by supervision from Dr Donald Meltzer. Later, I turned to the writings of Margaret Mahler and to those of Winnicott to help me to make sense of John’s revelations. This occurred in the following way. Throughout the sessions I’ve described, and after John’s treatment was finished, I was worried because the Kleinian formulations in which I had been trained did not seem to cover what I had experienced with John. In some desperation I wrote a paper about John’s treatment called ‘A Significant Element in the Development of Autism’ (1966). Looking through a research report I had had 10 Frances Tustin

from the Putnam Center (1953) in Boston, USA, which had been a research and treatment centre for autistic children and where I worked for a year after finish- ing the child psychotherapy training at the Tavistock, I found that what they had called ‘primal depression’ corresponded to what I had encountered in work with John. This type of depression had first been described by Edward Bibring (1953) who traced it back to the infant’s ‘shocklike experience of the feeling of helplessness’ (p. 14). In the paper I gave at a meeting of the Association of Child Psychotherapists, I used the term ‘primal depression’. After the meeting, I was asked if I knew that Winnicott had written about the primitive type of depression I had described in John, and was told that it was in his paper ‘The mentally ill in your case load’ (1958b). I say with some shame that I hadn’t read any Winnicott. I wasn’t really experienced enough to appreciate his work. I had to go to the library to read his books as I didn’t possess any of them. (Hindsight is always painful! This whole paper is about painful hindsights … But enough of this sackcloth and ashes!) In the chapter I had been recommended to read, I came across the following paragraph which seemed to be an apt description of the experiences I had been having with John. It was comforting to find that Winnicott seemed to be aware of the elemental levels of functioning I was encountering. He wrote as follows:

For example, the loss might be that of certain aspects of the mouth which 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 infant had reached a stage of emotional development which could provide him with the equipment for dealing with loss. The same loss of the mother a few months later would be a loss of object without this added element of loss of part of the subject. (Winnicott 1958a: 22; italics added)

Winnicott called this early type of depression ‘psychotic depression’ and distinguished it from ‘reactive depression’ which was the loss of an object recognised as separate from and not part of the body of the subject. This made such sense of John’s material for me that I began to use the term ‘psychotic depression’ for his ‘black-hole’ type of depression. In writing about ‘the loss and restoration’ of what she called the ‘symbiotic Downloaded by [New York University] at 03:54 14 August 2016 love object’, Margaret Mahler also seemed to be aware of the type of experiences I had had with John. She wrote:

What we seldom see, and what is rarely described in the literature, is the period of grief and mourning which I believe inevitably precedes and ushers in the complete psychotic break with reality. (Mahler 1961)

I felt that both Mahler and Winnicott were on the wavelength of the type of material that was troubling me. I also felt that Isca Wittenberg was on that The perpetuation of an error 11

wavelength when she adopted the phrase ‘primal depression’ (although it was not part of Kleinian terminology). In her paper ‘Primal depression in autism: John’ (1975) she performed a useful service in relating it to Bion’s ‘containment’ and his ‘catastrophe’ theory by describing it as ‘collapse into a particular kind of catastrophic depression’ (p. 56). She also says, ‘I did not feel that I was dealing with a three-year-old child but with a young infant, terrified of falling into an abyss’ (p. 59). Winnicott (1958a) also speaks of the terror of ‘falling infinitely’ and writes of a ‘flop-type depression’. John speaks of the terror of the ‘black hole’. Sheila Spensley (1985) has helpfully related ‘psychotic depression’ to ‘cognitive defect’ and ‘mindlessness’. These children have experienced a ‘mind-blowing’ trauma that has left them feeling that they have a ‘black hole’ of something being missing. They have experienced one of the ‘pitfalls’ incident upon human development and human existence. It has been catastrophically traumatic. Interestingly, a mute autistic child, who was being helped to communicate through ‘facilitated communication’, pointed to letters that made the following poem:

Black Hole Alone in Me Fearing ripping stretching Please let me be free from your grip Deaden (Evan, 30 October 1990) (Cited in Biklen et al., 1991)

In my anxiety to have formulations that seemed to make sense of John’s experiences, I adopted the orthodox psychoanalytical view (exemplified by Mahler and Bibring) of pathological autism being a regression to a phase of normal primary autism. It was a neat hypothesis. I clutched at it as to a raft because I felt baffled, helplessly adrift and ‘at sea’. Helplessness breeds the desire for certainty so I shut my eyes to the fact that this hypothesis conflicted with the findings from the baby observations that had been so much part of my Tavistock training. I must here express my thanks to Anne Alvarez (1992), Downloaded by [New York University] at 03:54 14 August 2016 whose recent book Live Company is a landmark in the integration of findings from infant observation to those of psychoanalysis. Anne struggled with me over the ‘normal primary autism’ issue. She didn’t say it was untenable because Mrs Klein or Mrs Bick said so, but she sent me papers by Colwyn Trevarthen (1979) and Daniel Stern (1983). Since these observers had no sectarian theoretical axe to grind I listened to her, and finally abandoned the notion of pathological autism being a regression to a normal infantile stage of primary autism. But I was then left with the problem of understanding material such as John’s which had been repeated by other autistic children I had treated or supervised. I felt it was too important an issue to be shelved, in that 12 Frances Tustin

clinical work which does not take this issue into account is missing a crucial bit of mutative understanding that is important in understanding the reactions of autistic children. I looked over my notes of the children I’d treated and looked at other people’s accounts of their treatment, and realised that a ubiquitous factor in their early infancy had been the perpetuation of a fused, undifferentiated situation with a mother who, after the baby was born, had felt herself to be a ‘non-person’, as one mother put it. I applied this to the clinical material appearing in therapy with autistic children.

The clinical material of autistic children I began to see that, as an infant, the child had felt so unified with the mother that abrupt and painful breaking of this sense of dual unity, when inevitably they became aware of their bodily separatedness from the mother, had seemed like the loss of part of their body which, until then, had seemed to be part of the mother’s body. This disruption during the suckling phase of infancy had seemed catastrophic for both mother and child. They both felt left with a bodily hole. The trauma of this violent wrenching apart precipitated autistic reactions in the child. I began to realise that, in seeing this perpetuated state of unified ‘at-oneness’ with the mother as a normal situation in early infancy, we had been extrapolating from a pathological situation and mistakenly seeing it as a normal one. This was an error we must be careful not to repeat. I now realise that the infantile state that was being re-evoked in the clinical situation was an abnormal one. I have come to see that autism is a protective reaction that develops to deal with the stress associated with a traumatic disruption of an abnormal perpetuated state of adhesive unity with the mother – autism being a reaction that is specific to trauma. It is a two-stage illness. First, there is the perpetuation of dual unity, and then the traumatic disruption of this and the stress that this arouses. My work has made me realise that sensations are the basis of both cognitive and emotional life. The normal infant develops a sensuous ‘skin’ that helps him to feel safe and which is permeable for incoming and outgoing experiences. As a protection against trauma, the autistic child has developed an auto-sensuous insulation that blocks incoming and outgoing experiences. However, they have a Downloaded by [New York University] at 03:54 14 August 2016 fringe awareness through which therapeutic interventions can percolate. It is very important for us to realise this.

Normal infantile situations and pathological developments As in all psychotic conditions, a normal reaction becomes exaggerated. In autism it has also become frozen. In normal infancy there are oscillations from ‘flowing- over-at-oneness’ to becoming aware of separatedness from the mother and the outside world. In this ‘dual track’, as Grotstein (1980) terms it, there are alternating The perpetuation of an error 13

flickers of awareness of space and of ‘no space’ between infant and mother. In the infancy of autistic children, these normal oscillations have not taken place. Something that is normally fluid has become frozen. Such an infant has become traumatised and frozen in a state of panic-stricken clinging in an adhering way to a mother who is experienced as an inanimate object that can be clutched. It is a fear reaction. These children are ‘in shock’. They are ‘scared stiff’. As I have tried to show in my books and papers (Tustin 1966, 1972a, 1981, 1986a, 1990a, 1991) this fear reaction seems to be due to the fact that a vulnerable infant (possibly with a predisposition to depression) has become aware of separatedness from the mother in an insecure mental ‘containment’, that is the quality of caring attention has not been adequate for this particular baby. This can occur, for example, with a depressed mother who, for various reasons, has felt unsupported by the father and by her own infantile and childhood experiences. In his inimitable way Winnicott describes this situation cogently when he writes:

If you feel heavy with sleep, and especially if you are in a depressed mood, you put the baby in a cot because you know that your state is not alive enough to keep going the infant’s idea of a space around. (1988: 20; italics added)

I have come to see autism as the reaction to an infantile version of ‘post-traumatic stress disorder’, such a child’s trauma being becoming suddenly aware of what we call space due to awareness of the separatedness of their body from that of a mother with whom they had previously felt abnormally merged, undifferentiated and ‘at one’ – that is in a state of adhesive ‘dual unity’.

Adhesive pathology I was alerted to this by papers by Bick (1986) and Meltzer (1975). Meltzer has described ‘adhesive identification’ for which Bick prefers the term ‘adhesive identity’. I have expanded their frame of reference a little, since the adhesiveness I have encountered in autistic children does not have the awareness of space associated with identification or with feelings of identity. I have conceptualized their sense of ‘contiguous’ (Ogden’s (1989) term), skin-to-skin adhesiveness as Downloaded by [New York University] at 03:54 14 August 2016 ‘adhesive unity’, or ‘adhesive-at-oneness’ or ‘adhesive equation’. They become aware of this adhesive closeness only retrospectively when it is disturbed and wrenching separatedness is being experienced. At this time, they experience a sense of loss of they know not what. Something is missing. John wonders whether it is his head? his penis? or that ‘red button’? For some patients who have had an overly close association with the mother it could feel like loss of the umbilical cord. One patient told me that he had imagined this closeness as being strangled by the umbilical cord. When this was felt to be broken, it provoked ungovernable panic and rage, as well as relief. It was the mixture of feelings that was so confusing. 14 Frances Tustin

Processes of identification, that is feeling similar to someone, require some sense of space between the child and other people. This helps them to feel that they have an identity. Identification is based on empathy. Empathy is important in ‘knowing others’, in the so-called ‘theory of mind’ that was discussed in Dr Cathy Urwin’s paper given at the 1993 ACP study weekend. (Dr Peter Hobson (1986) has written about empathy in autistic children and Dr Uta Frith (1985) has written about ‘The Theory of Mind’ in relation to them.) In adhesive-at-oneness, the child feels the same as someone and stuck to them as to an inanimate object. This helps them to feel that they exist. It is concerned with survival; with ‘going-on-being’ as Winnicott so well calls it. It is more perseverating than ‘adhesive identification’. Indeed, it prevents the development of identification. That which is normally a fluid oscillation of normal states of ‘at-oneness’ (which foster empathy) alternating with awareness of separatedness has become frozen into an abnormal perpetually rigid state of ‘adhesive-at- oneness’ (which prevents empathy). Alternating healthy swings between ‘at-oneness’ and separatedness are not possible. The child is frozen stiff with terror. Empathy, identification and indeed all psychological developments, such as what is popularly called ‘bonding’, and also experiences of ‘psychic birth’ and ‘individuation’ that are associated with processes of introjection and projection, are all prevented. The child does not feel, speak or respond to other people. He seems like a frozen automaton. This is never a normal infantile state. It causes confusion to label it as such. A lesson that I have learned is that the term ‘autism’ should be restricted to pathological states and should never be applied to normal ones. This is the error that the ‘normal primary autism’ and the ‘regression’ hypotheses have perpetrated. So far we have established that there is not a primary autistic stage to which autistic children can have regressed. Let us now think about the concept of regression. Regression means going back and behaving in terms of an earlier stage of development. In some of the aetiological formulations we have been discussing, autistic children have been conceived of as living in terms of an unchanged early stage of infancy. This has led to the notion that it would be helpful to let them behave as infants so that they could continue growing from there – the so-called ‘regression therapy’. In my experience, this has done a lot of harm. I remember Downloaded by [New York University] at 03:54 14 August 2016 how shocked was the commonsensical George Stroh when he took charge of High Wick Hospital for psychotic children, to find the children pushing each other around in prams and using feeding bottles. It was clear that this had not been therapeutic but deleterious for their development. In the clinical situation, John showed clearly that situations in his infancy had been evoked by seeing the friend of his mother feeding her baby at the breast. However, he was not behaving as a baby or regressing to babyhood. He was a five-year-old boy re-enacting a trauma that he had experienced as an infant. He now had more resources than when he first experienced the ‘mind-blowing’ traumatic crisis of awareness of bodily separatedness that had left him with the The perpetuation of an error 15

illusion of a ‘black hole’ at the root of his being, of something being missing. He was at the mercy of black despair. The Argentinean psychoanalyst Dr David Rosenfeld (1992) has described how his work with Holocaust victims has shown him that their traumatic experiences had been ‘preserved’ and ‘sealed off’ by autism, ready to come up later, intact and vivid, with every detail of the original experiences clear and sharp. It was an active re-evocation and re-enactment. They now had more capacity to bear and deal with those terrible experiences than when they had first experienced them. With autistic children, the traumatic experiences of bodily separatedness are triggered into action by present-day happenings, often in the transference situation of the analysis, such as breaks in the continuity of expectations of the analyst’s presence. It makes a difference as to how we handle such material whether we see it dynamically as happening in the ‘here and now’, alive with new possibilities for ongoing development or merely as a repetition of past happenings. In therapy, it is usually the infantile transference that lifts these past happenings into the present day. This makes them into a new experience. It is not just the recapitulation of an old situation, but a re-enactment of the old situation with something new injected into it. This can bring hope. A psychic catastrophe can become a psychic opportunity. Dr Sheila Cassidy, who had been imprisoned and tortured in Chile, recently described in a radio broadcast her attempt to go back to Chile in order to relive the traumatic experiences in a new way. She said that she thought that it would be like opening a Pandora’s box with demons at the bottom. She knew that the evoked memories would be extremely vivid, but she would have the knowledge that it would be safe to be frightened. She was hoping that ‘it would release some of the things that had kept the hatches down’, as she significantly expressed it. Obviously, she thinks that it is going to be a new releasing experience, not just the recapitulation of an old one. She is dealing with it in a forward-looking rather than a backward-looking way. This will counteract ‘the backward pull to the inanimate’ (Freud 1920). So it was with John. His behaviour in the clinical sessions demonstrated clearly that, as Valerie Sinason (1992) has pointed out, ‘the flashback of the trauma’ repeating itself needs to be seen as a communication and not as an obstruction. He could begin to communicate about his suffering, and so the straitjacket Downloaded by [New York University] at 03:54 14 August 2016 of autism that had kept his explosive ‘firework’ feelings in check could begin to be dispensed with. Instead, these feelings could now be felt to be contained within an understanding, interactive, disciplined and disciplining relationship. This helped him to use his emergent symbolising capacities. It was a symbolic re-enactment. It was the beginning of the ability to play.

The effect of this modified view These modifications are not merely an academic exercise. This revised view of the aetiology of autism will bring about a significant reorientation in our approach 16 Frances Tustin

to the treatment of autistic children. It will affect the way we respond to and talk to such patients. It means that we will talk to them as if we think that they can understand what we are saying. We will not talk down to them. Also, if we see autism as a serious developmental aberration it will mean that we will be firmer and less indulgent in our approach to them than if we see it merely as a regression to a normal stage of infantile development. We will be more active to correct deviant tendencies. It also means that a sentimental and unduly romantic view of the early mother and child situation will be modified. We will take a more stark view that the craving for a superhuman mother can never be realised and that an important part of early learning is the gradual coming to terms with this frustration and all that this disillusionment implies. We will have a more compassionate attitude towards the mothers of these children. We will also know that we cannot achieve the perfectionism that these children seem to demand of us.

Afterthoughts Some thoughts from another of my papers are relevant to the theme of this present paper. As Bion (1977b: 19) has shown, the traumatised patient experiences ‘pain but not suffering’. They are in the pain. The pain is in them. They are enveloped in it. Autistic children have been insulated from the pain by autistic procedures that I have described elsewhere. In therapy with these children, as the pain is experienced and abated, their autistic insulation begins to be modified. This means that the suffering begins to be felt. The wounded child becomes more open to healing by the therapist as (s)he becomes able to bear the suffering of mourning for loss. (It is significant that the word ‘suffering’ is derived from the latin verb ferre meaning ‘to bear’ or ‘to carry’) … The pain of the trauma has caused autistic children to turn away from people, but the suffering that follows as the trauma is re-enacted and the pain mitigated stimulates the need to turn to people for help. As they are freed from a ‘repetition compulsion’ of the traumatic experience, they develop a cooperative relationship with the therapist and with other people. As this occurs the autism begins to

Downloaded by [New York University] at 03:54 14 August 2016 wither away. They become able to look at the trauma [and to represent it] instead of being in its thrall. A psychic catastrophe has become a psychic opportunity (Tustin 1993). This transformation occurs because they begin to turn to the ‘lifegiver’ as Symington so well expresses it (Symington, 1993). A week or so after the meeting in which this paper was presented, Juliet Hopkins sent me a photocopy of Henry Moore’s 1983 sculpture of ‘Madonna and Child’. This depicts a mother with an abdominal black hole in which a penis-like child is inserted. This is strikingly reminiscent of Joyce McDougall’s ‘Chasmic Mother’ and ‘Cork Child’ that is used to fill the hole of the depressed mother’s The perpetuation of an error 17

emptiness and loneliness (McDougall 1989: 78). This made me wonder whether the image of the Madonna and child, which has such psychic significance, had influenced the tenacity with which the notion of a pre-relationship state of normal primary autism had been held. Jeanne Magnana also drew my attention to the fact that, in feeling part of the mother’s body, John could have been re-experiencing the sensations he had had before he was born and which continued after birth. The mother-infant situation after birth had reinforced the illusion that his body and the mother’s body were a ‘dual unity’. This had perseverated and had become a permanent unchanging state.

Conclusion As some of you may know, my husband has acquired fame as a writer of psychological limericks. When I told him about the theme of this paper, he gave me the following limerick:

When beliefs need some modification, We make it with much trepidation, For our world is then new, And things seem all askew, Till we’re used to the new formulation!

This applies both to therapists and to the children we treat. As the French psychoanalyst Professor Didier Houzel so well puts it, our work should be informed by ‘a movement of letting go in which the spirit accepts losing mastery of its object of knowledge in order to allow itself to be surprised by the unexpected and be questioned by change’ (1990: 56). As I said earlier, the misconceptions I have been talking about have been more prevalent and influential on the European continent and in the USA than in Britain. It is hoped that the suggested modifications will facilitate communication between workers with autistic children both at home and abroad. Sorting out these misconceptions will help us to avoid insu- larity. When there is consistency in views about the aetiology of childhood

Downloaded by [New York University] at 03:54 14 August 2016 autism, we shall be able to talk to each other better. I have come to think that one of the factors that has caused the persistence of the error under discussion is the atmospheric adhesive quality of the clinical material we are trying to understand. It is difficult to be clear-headed when dealing with such elemental, persistently ‘sticky’ material. This paper has been a record of attempts to clear a way through a mass of such primeval material so that we can be freed from being ‘stuck in the mud’ (this being the best description of the state of an autistic child that I know). In this attempt, it will have been obvious that the work of my psychotherapy colleagues has been indispensable. As a token of my gratitude, I am pleased to be 18 Frances Tustin

able to present this my last paper to the Association of Child Psychotherapists of which I am proud to have been made an honorary member. In writing it I have been helped by colleagues who read the various drafts I produced. They have helped it to grow.

Note 1. This paper was originally presented to the ACP Study Weekend, March 1993, and was originally published in 1994 as ‘The perpetuation of an error’, Journal of Child Psychotherapy, 20: 3–23. Downloaded by [New York University] at 03:54 14 August 2016 Chapter 2 Stuck between two worlds Autistic defenses and the experience of premature birth

Angela Sowa

Introduction Intrauterine life and the experience of birth leave discrete psychological traces that are both difficult to determine and yet pervasive in their imprint. For example, the fetus’s transition from living in a floating state to beginning to feel the boundaries of the womb against its own body appear to be prerequisites for the infant’s feeling of a sense of skin. For the mother, the movements of the fetus kicking and stretching are powerful indicators that the life she carries inside is different from her own. So, too, in the experience of the birth – through the contractions, the confinement of the birth canal and the delivery process – there is an imprinting for both mother and baby that their life together is being transformed and that psychological work is necessary to expand into this new space. In the best of circumstances, the experience of a live birth provides for both mother and father the needed impetus to care for and love this new creature. The infant, in turn, will send powerful social cues concerning its ongoing needs and will demonstrate through seeing, molding, and voicing an awareness of others around him. However, what about the experience of the infant who is ‘not ready to be born’? We can only imagine the magnitude of psychological trauma to an infant born prematurely, who is most often deprived not only of a normal birth experience but of a most essential time, sometimes as long as two to three months of development – both physical and psychological. The infant is completely unprepared to meet the assault of the outside world, made unbear- Downloaded by [New York University] at 03:54 14 August 2016 able not only by the loss of the ‘mother-body’ – the mother that harbors me and is me at times – but also by the lack of ordinary sensual contact that a full-term infant might enjoy as recompense for loss of life in the womb. What was destined to be a sensually rich and complex experience of smelling, touching, seeing, and hearing is now a ‘stimulus scramble’. ‘Sensuous objects’ that are the entitlement of the newborn are experienced instead as ‘assault objects’, and even more often as ‘indeterminate pain and suffering’, leading for survival’s sake to a necessary loss of awareness of an outside world. The premature infant is a ‘fetal-infant’ – not only premature but extremely immature – and this immaturity, while affecting childhood development, must be understood in the 20 Angela Sowa

discrete phenomena that emerge separately from the forms of childhood pathology that they mimic. Psychoanalytic child therapists are uniquely suited to differentiating these qualities, and Frances Tustin in particular offers us clues to what it may be like to live stuck between two worlds (fetal life and infant life). However, I believe that the terms ‘ordinary’, ‘normal’, and ‘pathological’ are insufficient descriptors that can seal over what for many is a wordless condition until such time as we more fully understand this between place’s imprint on the infant and his family, as well as the culture within which it is being sustained. In this chapter, I will present details of an hour of observation of an extremely premature infant whom I followed weekly for the first three years, and then monthly for the fourth and fifth years, according to the Tavistock model of infant observation. I present the hour in full to give the reader the opportunity to examine the integrity of the hour, including unconscious links that I may have failed to pursue. The theoretical contributions of Frances Tustin, regarding very early states of mind, allow us to understand the moment-to-moment complexity of the hour. Although mainly focusing on treatment of autistic children, Tustin was aware of the plight of premature infants and commented on them (1986b). She was a keen observer of children’s play, particularly where unelaborated and confusional experiences – such as I will describe here – impinged upon natural capacity. Tustin points out that as far back as 1965, Shevrin and Tousseing stated that too much as well as too little stimulation have a deleterious effect on the infant, resulting in autistic-like reactions. Tustin states that early defenses involve omnipotent control of the senses, creating a flat one-dimensional world. This co-opting of the use of the senses collapses the infant’s earliest forms for receiving and conveying information, creating the impression over time that such children are damaged neurologically and/or mentally impaired. Tustin further states:

It is obvious that impediments to taking in the outside world can mean that sensations in the child’s own body remain of undue significance. (1972a: 74)

It is hard to overestimate the significance of this statement in even minor failures to perceive – the resonance of inside and outside is of such importance to the Downloaded by [New York University] at 03:54 14 August 2016 development of the imagination, particularly to phantasies of the body. This lack of perception takes on various forms: the lack of a sense of closeness and separateness, of hard and soft, of texture and form. In most infants there is potentiality for all of these capacities, yet the growing and building, the pruning and expanding must all occur within a framework of containment within the mother/infant relationship. The human capacity for the perception of sensible qualities is innate, but it must be mediated through the emotional containment of an adult mind, most often the mother or the father, because the state of reverie so necessary to the development of the imagination is built upon the multiple resonances of self and other and self and the environment. In the event of premature birth several Stuck between two worlds 21

circumstances intrude upon this capacity. The infant is unprepared mentally (too immature) to meet even the ordinary stimulus of living in the world. Numerous and repeated painful medical interventions hijack what would ordinarily be experienced as a playing field for the perception of sensuous objects. Extremely premature infants are often faced with ‘unmediated stimulation’. Without sufficient human contact, the hospitalized premature infant is unable to decipher the information coming from the senses. Information is not experienced by the infant as ‘too much’ or ‘too little’ because its experience may not yet have such parameters. Being unable to process at even this most elemental level, the infant experiences a ‘stimulus scramble’, which forces into play the most primitive of defenses – the shutting down of the capacities for perception – or a co-optation of normal modes of gathering information. This leaves the infant in a one-dimensional world devoid of the experiences of delight and desire, resulting in a maturational catastrophe and the collapse of the normal routes for the development of symbolic thought. Even more so than the full-term infant, the fetal-infant who resides somewhere in the interstitial space between ‘being born and not quite born’ needs containment to deal not only with external stimuli but also with fluctuating internal states. I am speaking here of moments where the infant is in a state of suffering, unable to manage hunger, digestion, evacuation, and its own extremely immature mental processes.

Sam Sam was born at 24 weeks gestation, a first child to parents in their early forties. He spent ten weeks in a neonatal intensive care unit (NICU). The first two years of Sam’s life were marked by much uncertainty as to how fully he would be able to recover from the physical and psychological traumas of prematurity, not the least of which was the separation from his parents while in the neonatal intensive care unit. Sam’s early months were marked by feeding difficulties including sucking anomalies, hypersensitivity to overstimulation (especially through being touched), insufficient molding, and gaze aversion. Early on, he exhibited anxiety by head and body thrusting and a weak whimpering cry. Many times, Sam was neither capable of evoking his parent’s help nor of making use of their ministrations. The parents were left to guess about Sam’s states, which affected their Downloaded by [New York University] at 03:54 14 August 2016 ability to feel alive and excited about their infant. Sam’s parents worried, particularly his father, that he would ever be able to recover from the trauma of his too early beginning. Slowly, they created a world around Sam in which he would feel ‘minimally disturbed’. While this seemed effective for the time, I worried that Sam may miss forever certain developmental milestones for lack of appropriate stimulus. In the second year, Sam began to show signs of obsessional and autistic behaviors. He would switch lights on and off and use monotonous language. Although at times he was inconsolable, for most of the first 18 months he was unable to identify and express frustration, fear, and desire. (His first expressed fear of a 22 Angela Sowa

phobic nature was to a five-gallon empty water bottle that his parents were filling up with coins for his college education.) Otherwise, he appeared indifferent to the world. He did not recognize himself in the mirror. He only clearly recognized and called his mother by name at around age two; until then he was unable to engage in even rudimentary fantasy play. The recognition of his mother, himself, and others elicited a near avalanche of development. By the beginning of the third year, he began to make clear and steady progress. He became more careful about himself (less accident-prone) and started to show a need to be near his parents, engaging them fleetingly. He soon began to demonstrate a store of understanding about objects and things. But, as we shall see, he often identified his mother and father according to the thing-ness that that they were and that they could provide (the cooking Mommy, the sham- pooing Mommy), not always being able to hold the whole Mommy and the whole Daddy in his mind. By the time of this observation at two years, seven months, Sam is a much more accomplished little boy, coming to life in many ways, and yet still struggling to express something about his early traumas and still engaging in primitive defenses to shut out anxiety. We will see a number of Sam’s experi- mentations with liquid states that evoke his anxiety, terror, and dangerous behavior. We will also see how his play can only be sustained through the continuous mindfulness of his mother, who is, understandably at times, exhausted by his idiosyncratic behaviors. At this point, Sam’s ability to symbolically express these states – to live life in metaphor and to experience joy and beauty – is very tenu- ous, often verging on collapse. His parents by this time had learned to live with one foot in his autistic-like world, protecting him by allowing for his extreme defenses while showing him the way toward emotional warmth and comfort. Eventually a love of music and attention to small creatures, as well as the constitutional strength of his parents, will pave the road to a life lived more richly and connected to a universe outside of his little room and his self-enclosed world. Although I present the hour in six sections with a discussion following each one, I recommend that the reader first skip the discussions and read the hour in its entirety (paragraphs numbered 1–18) to allow the flow of the hour to emerge and have an opportunity for emotional response to the descriptive material without the encumbrance of the author’s thoughts. Downloaded by [New York University] at 03:54 14 August 2016 Observation hour of Sam at two years and seven months – Part 1 (1) I arrive and find Sam and his mother, Rita, at the front steps talking to a neighbor with little children. Rita gives me a quick ‘hi’ and keeps talking. I say hello to the two little visitors who look at me quizzically. I say hello to Sam. He does not give me the usual big smile. The woman says to her children that Sam has a visitor. She politely says goodbye and leaves. (2) Rita tells me she is unpacking groceries from the car. Sam comes down the stairs and shows me the watering can saying ‘more wa-er’. I think I understand Stuck between two worlds 23

his poor diction, and then he leads me to the faucet behind some big bushes. Sam says, ‘wa-er, wa-er.’ Rita sees us and says, ‘Oh, he wants water.’ I say, ‘Shall I fill it?’ Rita says yes. I fill it, and Sam returns to the bushes and waters one that is obviously dead. Rita jokes that he found the dead one. (3) We fill the water up again as mother places the bags of groceries on the front porch. Sam wants to bring the can onto the porch. I watch. First Mom says no and then says, ‘if you want, but I’ll help.’ She helps Sam put water into the potted plants; however, there are some he cannot reach so Rita does it herself. When Sam lets go of the watering can, he takes hold of Mom’s arm, going up and down on his toes somewhat matching this by opening and closing his hand and saying, ‘wa-er’. Then he takes the empty can to the faucet. This time I do not follow, and Rita tells Sam that it’s time to go inside. He immediately drops the can and says ‘inseye’ and quickly comes up the stairs. He sees a piece of wood on the porch and hands it to me saying something. I say, ‘Oh, thank you,’ and he seems pleased. I comment on the woodworms that have carved designs in the wood. Rita (who has returned from the kitchen) says that is what attracted her to it when she saw it on the beach. I put the wood down and we go inside. We carry the six bags inside and Rita comments that the family drinks a lot of juice, thus there are so many heavy groceries.

Discussion Sam’s tentative ‘Hi’ mirrors his mother’s quick greeting. Mother may have been ambivalent about my arrival since it interrupts their engagement with their neighbor, who, sensing the demarcation of space that my visit implies, politely takes her leave. Then Sam quickly claims my attention by engaging me with the watering can. As I am in my role more as an observer of than a participant in the scene, I ask Rita if it is okay to fill the can. This is not just a permission-seeking question but serves as a way of involving Rita in Sam’s fantasy about the water. When Sam chooses to water a dead flower, she comments. I am aware that the word ‘dead’ is highly charged for this family. Even in the moment, through Rita’s hint of sarcasm, I feel a bit of a twinge about their joint history together – the loss of the pregnancy, the prematurity, and the fight for Sam’s life. Rita’s comment is directed toward the uselessness of watering a dead object and perhaps pertains to Downloaded by [New York University] at 03:54 14 August 2016 her confusions about what represents aliveness and deadness for Sam – especially at times when he engages in repetitive routines. The third paragraph demonstrates a lively scenario where Mom picks up on Sam’s desire to water the flowers that are on the porch. I notice that the alive flowers are those that are close to Mommy. First she says, ‘No,’ perhaps intent on her grocery project, and then, sensing the importance, she reclaims Sam from me and says, ‘Yes.’ As the two water together, they become one – Sam almost becoming water as he opens and closes his hands and lifts himself on his toes, his eyes intent on the water coming from the spout, his head tilted forward to match. He appears very pleased. He proceeds to the faucet with the watering can again, 24 Angela Sowa

but, at the beckoning of his mother, he drops the ‘can object’ immediately and follows her inside. Sam proceeds up the stairs with speed. I don’t know how much of the activity with the watering can is still sloshing around inside of him or if he has split it off, demonstrated by suddenly dropping the can. He appeared to be under a threat of losing his mother to the inside of the house, and maybe that was especially poignant after the moment of joining her in watering on the porch. I had a further thought that he was shocked that without his knowing, ‘the watering can and the mother of the porch’ had somehow become completely erased and replaced with ‘the mother inside the house now’, causing a sudden but brief anxiety. Coming up the stairs, however, Sam stops. Perhaps his physical presence on the porch helps him remember and relive the good feelings with his mother or, alternately and more defensively, he ‘sticks himself on’ to a piece of driftwood, which he picks up and shows me. He tenderly hands me the item, which, as it turns out, is an object of importance to his mother. It was clear that his mother had shown him the woodworms before, so he is now offering me the gift of that knowledge. Mother who has now returned to the porch also joins in by adding her emotion to the moment, confirming the object’s importance. The question might be asked: ‘What is the role of the observer thus far in this hour?’ It appears to be an instrumental one, a sort of conduit for emotion. Both Sam and mother are making use of the observer as a way of elaborating their life together: broadening it, bringing their fantasies to a place of being more outside – on the front porch as it were. If we accept Bion’s idea that dream-life is continuous day and night unless interrupted by resistance and anxiety, then we can accept all of their communications as expressions of the phantasy life between them. Even the comment about juice – ‘the family drinks a lot of juice’ – harkens both backward and forward in time and may pertain to the significant emotional needs of the family. Anxieties about liquid states and liquefaction are prominent in Sam’s life and his mother described him as just slipping out of her womb. By himself, Sam only waters the dead plant but with his mother by his side, water becomes something – it is given an importance far beyond a substance sliding out of a can. This will be the first activity (reported by the parents) that Sam imitates – mother watering the flowers in the house. Downloaded by [New York University] at 03:54 14 August 2016

Observation of Sam – Part 2 (4) Inside, Sam has run into the kitchen. I don’t remember what happens here. I sit down at the kitchen table and Sam comes close to me as if he wants to interact, and then grabs a chair and then a second one to put up against the sink. I note that this is the first time he has pulled two chairs to the sink and wonder what this could be about. (5) Sam gets on the chair and retrieves his baby bottle of water and his cup of juice, which has a closed top. He says, ‘jus,’ and sucks on the sippy cup while Stuck between two worlds 25

pressing his bottle against the side of his head stroking his hair ever so slightly. He alternates taking a few sips and then sucking on his beloved bottle. His mother tells him he is drinking mango juice, and Sam says, ‘mango jus,’ shaking his head forward as he tries to articulate it clearly. He immediately runs to the refrigerator and points to the mango juice in an urgent way. His mother confirms that indeed that is the juice but that he should drink it from his cup. When he tries to climb into the refrigerator, she says lightly, ‘No, Sam,’ in kind of a sing-song voice. (6) Mother then continues to unpack the cold groceries. Sam is standing slightly behind her, investigating the open door. One by one he unscrews three tops on bottles in the door. He almost pours the soy sauce on the floor but stops himself at the spilling point and replaces it in the shelf. Mom then sees that he has uncovered the bottles and says jokingly, ‘and so close’ and then puts the tops back on. Sam then returns to the sink. (7) At the sink, Sam calls to his mother for water. She goes over and fills a bottle up for him, which he dumps and she refills about a half dozen times. One time, the water squirts over the faucet slightly. Sam notices this and tries to reproduce the event by spilling the water directly over the faucet. Mom then says, ‘So now you want to do it,’ referring to the action. Rita then returns to the refrigerator. Sam plays a bit more, talking to me about the water. He says, ‘ge down,’ and gets off the chairs. (8) Sam goes into the master bedroom, which is under construction, and attempts to put a plug into a socket. I’m surprised that the socket is not covered, as last week the same event occurred and Rita went looking for a cover. I notice that I become anxious that someday somewhere Sam will succeed in his persistence and hurt himself. I call to Rita and she says that they keep losing the covers. Sam shows me the vacuum cleaner and says, ‘dir,’ and tries to put it together unsuccessfully. I say, ‘brm, brm,’ and he laughs and repeats what I say.

Discussion Sam pulls two chairs to the sink for the first time. Is he bringing an ‘imaginary other’ into his regular and somewhat problematic scenario at the sink, a kind of autistic activity of filling and emptying his bottle that had been boringly repeated Downloaded by [New York University] at 03:54 14 August 2016 week after week? Will this inclusion of a third represented by the second chair (my mind) allow it to be a bit more spontaneous, more pleasurable this time than others? Sam grabs for his bottle and juice, sucking from the sippy cup while stroking the side of his head gently with his bottle. Perhaps his mother’s statement about juice drove him to feel the sudden need for his bottle and cup. Here, he uses, as he has done many times before, both items to ensure that the break will never happen again. The sensory stimulation he provides for himself, although quite repetitive, is not as rigid as the days when he would stand at the door jamb endlessly putting the lights on and off, on and off. The ‘on and off’ activity felt 26 Angela Sowa

autistic and defensive. The juice and bottle seem to be autistic sensuous objects (both soft and hard) with the potentiality, at times, of being transitional in the Winnicottian sense (Winnicott 1951). At this point, a surprising event occurs. When mother mentions juice, Sam attempts to climb into the refrigerator. The phrase ‘mango juice’ uttered by his mother is enough to suggest a separation that may have felt intolerable. It is as if he must be one with the juice, all of it. He must bring it all together – the juice in the sippy cup, in the refrigerator, and in his body – and even the suggestion of symbolic form through language is unacceptable. I think this confusion may suggest that indeed there was a level of splitting that had occurred as Sam consoled himself with the bottle and the sippy cup, that perhaps he had momentarily gone to a place where he was in need of no one. ‘Having everything’ in the bottle breast and in the sensations he provided for himself, he needn’t be aware of juice here, there, and everywhere. Just as his defenses maintain the juice in one place only and under his omnipotent control, likewise Mommy and all things vital to him can be rendered immoveable, unchangeable, and therefore predictable and perfectly reliable. In the past this type of defense served to seal Sam off from experiencing more unbearable anxieties and perhaps even dread. Switching lights on and off, he was in control and kept separation anxieties at bay. However, now, a more capable and more connected little boy of the front porch moments before may want more for himself. Did he want to be helped out of his confusion related to the earlier feeding traumas, which were encapsulated in this perfect bottle/breast creation? Mom says, ‘No, Sam,’ in frustrated sing-song when Sam tries to climb into the refrigerator. The tone of her voice makes me feel she is sensing the regression to an earlier moment (through the oddness of his behavior) but also feeling frustrated and not wanting to deal with the pain that is both his and hers – the pain of Sam having slipped out of her womb, as well as the unsuccessful nursing. But neither does she shoo him away; rather, she allows him to stay by her side even though he is being a bit bothersome bumping into her and messing with the bottles in the door. Sam then escalates by opening one by one three bottles of sauce, ‘almost pouring them’ onto the floor. Here Sam demonstrates his near- liquid state. I believe him to be in a psychologically precarious moment. He has Downloaded by [New York University] at 03:54 14 August 2016 momentarily let go of the bottle/ breast and sippy cup. I don’t remember where they went. Perhaps the physical closeness to his mother (brushing against her) allows him the capacity for the expression of an ‘almost spilling’ – a play at spilling! When mother says, ‘And so close,’ it is with affection and a smile as she looks at me knowingly. Perhaps she is grateful for this new and slightly more evolved Sam and this helps her to feel her connection to him momentarily. But she soon returns to her task and leaves Sam for a moment standing, not knowing quite what to do. Was mother unable to connect unconsciously to the full meaning of his work – the expression of his near liquefaction if he gives up his bottle/ breast? I suspect that it was hard for Rita to sink into her own pain about the loss Stuck between two worlds 27

of their breastfeeding connection at the level of unconscious phantasy, which would have been necessary for her to receive his full communication. She would have had ‘to dream his plight’ (allow her unconscious phantasy to be affected by his), and, in doing so, he would have broken through her own obsessional defense against pain – her quite lengthy activity with the food in the refrigerator. Sam’s solution is to return to the sink. Having needed more from Mommy, he then engages in a repetitive activity which I had observed many times before – a sort of unelaborated scenario of filling and spilling that did not seem to express much fantasy and joy. Even though his mother comes to the sink at his beckon, Sam has rendered her a functional Mommy only – the ‘filling-up-the-bottle-only’ Mommy. In filling and refilling the bottles at the sink, he eradicates any space he created in the fantasy play of the ‘almost spilling’ where both states, empty and full, can coexist as a concept in his mind. The second chair (perhaps standing in for an alter ego or for a dependence on a live object) is also not of use to Sam now that his defense has set in. Sam gets down and runs into the bedroom, further escalating his behavior by playing dangerously with an electrical socket. He pushes the observer to intervene. I believe that the repetitive activity at the sink served to deaden him and thus he engages in risky behavior to bring himself to life and to the attention of others. Rita and I say some words about the socket and I say, ‘No,’ firmly to Sam. Though I notice that I did not write this in the notes, I remember feeling frustrated, almost angry, with Sam that he requires such constant tracking, perhaps mirroring his parents’ exhaustion at times. Without a more developed superego to advise him of the proper use of objects, his ‘knowledge base’ – what he knows about how things work – can be quickly put to perverse use. In the scenarios described above, we can see that Sam moves in and out of his capacity to live ‘in flexible form,’ and life around him becomes rigid and heavily codified, lacking the pleasure of spontaneity and surprise. The bottle/breast that sometimes serves as a soothing transitional object at other times becomes an autistic object devoid of the movement that ongoing phantasy life offers. At the sink, Sam also rendered mother as a functional object and, in this trade, lost the mother that he could have had, that is someone capable of expanding his horizon. It is less clear just how this potentiality was lost – my suggestion above being that it was the unconscious phantasies of both that became frozen in place, making Downloaded by [New York University] at 03:54 14 August 2016 them incapable of influencing each other, consciously and unconsciously. Tustin was actually the first to understand this stalemate by stating that infants who have encapsulated parts are not able to make use of projection and projective identification even though they may be suffering.

Observation of Sam – Part 3 (9) I don’t remember how this happens but Sam calls one of the cats ‘Baba’, and Rita says to me, ‘He sure keeps track of these cats. We go through this several times a day.’ Rita holds his hand to go down to the basement to find the cats, 28 Angela Sowa

herself calling, ‘Baba.’ Sam looks up at me and says, ‘Go so.’ Once again, I notice some expressiveness as he moves his head and speaks, clearly wanting me to follow. He repeats ‘go so’ pointing his finger demonstrably. He does this a few more times and, once at the bottom, runs into the cellar saying something inaudible. Then Rita calls for Baba and he repeats it. Baba is sleeping on a chair and he barely opens his eyes. Sam points to the cat food and says, ‘ca foo.’ He points to the bottles of water and says ‘wa-er’ and then to the washing machine and says ‘dir-y.’ Rita tells him that Baba does not seem ready to come upstairs and that he will come later. We go back upstairs.

Discussion Sam engages his mother in another repetitive activity – going to look for Baba the cat. Mother had told me that she didn’t quite understand why he always needs to know where Baba is and that he does it several times a day. The cat has actually played a very important role in Sam’s life. A small black Burmese, Baba lay by Sam’s side since he was an infant. Many times, Sam would pull, even mouth, and attempt to suck on his tail and Baba would just sit up and rearrange himself but still always in reach of Sam who would once again, aggressively at times, pull him in uncoordinated ways. Baba felt to me to be an object of importance for Sam – a reservoir of lost and confused parts. But I feel that in this scenario, Baba has not yet become fully internalized in Sam’s mind, so he has to check in with him. But the checking in for Baba does not yet feel emotionally significant to Sam, rather just a marker, a hint of where and perhaps how the trauma has been stored. As we go down the stairs Sam starts to name things, but it feels less as a communication of meaning and more as a way of putting and keeping things in their place and at bay. He tells me several times to ‘go slow’ and he names things, but the words feel worn, unassimilated, and echolalic. He is not speaking words from inside himself but his parents’ words. Not yet of a superego nature (an internalization of his parents), the words are simply riding on the edge of his sensorium. They are not really inside, that is used for being made aware of the danger to which his parents may be alerting him, but rather used for ensuring the predictability of the basement ritual. I am also aware that at this point, Sam only speaks single words, rarely a phrase, and I know his parents are growing very Downloaded by [New York University] at 03:54 14 August 2016 concerned about this lack of evolution in development. In the basement, I lose track of Sam and find myself focusing more on the mother’s story, which interestingly enough I do not report in the observation. I only remember that a short but emotionally significant conversation took place between Rita and myself that I think was related to her own childhood. It may have served to help her connect to herself because she then begins to talk to Sam about Baba. When Sam insists on bringing Baba upstairs, she then asserts Baba’s separateness by telling Sam gently that Baba is not ready to come upstairs. Sam accepts Mom’s statement, seeming to have received the unconscious communication that Mom understands something about him and Baba. Stuck between two worlds 29

Observation of Sam – Part 4 (10) Mother returns to her groceries and Sam is walking around the kitchen and bedroom, and at one point I follow him into the master bedroom but fail to locate him. I think he may be hiding (which would be a new activity for him), and I yell to Rita playfully, ‘Have you seen Sam?’ She playfully calls back, ‘No.’ I do this several times and then get worried that Sam is stuck in a dark closet, and I open the door and say, ‘There you are.’ Sam is tucked into a tiny hole that just fits him and he only slightly registers some playfulness, but I also sense some fear registered in a sort of non-response to me followed by running out of the closet and away from me. He repeats the event (I hesitate to call it a game), and I open the door, this time less playful and more serious, and I say, I see where Sam is. He looks at me a bit blankly again but gets out and runs more playfully and closes the door. I get a sick feeling inside as if I do not understand what happened and it felt dead serious and I wonder if Sam is tired of having me follow him around. (11) On the other side of the door, it sounds like Sam is calling maybe for me. I knock lightly and when he opens it, I hide behind the door. He sees me and laughs. Then he closes the door with Mommy on the other side and starts yelling ‘Mommy’ as if he did not know how to open the door, which he does. His voice seems more upset, and I can’t really tell if he’s playing. Rita answers him from the kitchen and says, ‘I’m here, Sam.’ He continues to call her. It did not feel like he was afraid of me but more like he would never reach Mommy again. He turns around and then realizes he has another way out of the room, an opening the carpenters have not filled in that leads back to the kitchen. (12) As he is climbing through, Rita, who by now has sensed that he may want her, comes through the door. Though she comes in, Sam continues to go through the opening to the kitchen. She tells me that Sam has been hiding in that new closet, that it seems just to fit him, and that he goes into dark places not seeming to register fear, just staying there. She says this as if she finds the behavior strange, almost suggesting, though not saying, that he needs to be retrieved, which was exactly the feeling I had earlier, though I did not say this to her. (13) In the kitchen, Sam finds his bottle and sucks on it, alternating juice and bottle, this time in more of a daze. Baba the cat comes in. I don’t remember what else happened except that Rita pointed out that Baba is here. Downloaded by [New York University] at 03:54 14 August 2016

Discussion A game of ‘hide and seek’ so familiar to all goes awry here, demonstrating that there is nothing simple at all in the play of being lost and then found. In fact, I misnamed this activity as a game. Sam went into a space that somehow lost the reciprocal components of there being an inside and an outside, someone hiding and someone looking. Perhaps it did have some ‘let me be lost and then found’ potential, but once Sam was ‘in the hole’, it turned into a deep dark space from which Sam could not connect with another. Mom told me that Sam had been doing 30 Angela Sowa

this in a way that was also unnerving to her and her husband, confirming my feeling. In the ensuing weeks I would hear more about how Sam would hide in a closet for what seemed to the parents like a long time. They would find him inside with a puzzled and serious look on his face, neither happy to be found nor playful. Out of the closet Sam makes another attempt at the ‘hide and seek’ game, closing the door and calling me. When I hide and he finds me, he laughs with delight, but when he tries to hide from his mother the mood changes. We clearly see Sam’s attempts at play that somehow are intersected by anxiety and terror. It is different when Mommy is out of sight. He feels that she is not hidden but gone. When Mom comes around to Sam, it is not enough. The moment is not a reunion as it might be for a less traumatized child. She is not the same Mommy he last saw in the kitchen. Despite her presence beside him now, he is driven still to go toward the place where she was last standing in the kitchen, seeming surprised she is no longer there. We can see Sam’s defenses at work trying to put the Mommy back where he had her by the stove. We can also see very clearly the elements of the original trauma coming together: having Mommy and all of a sudden not having Mommy, and being instead in a dark hole without her heartbeat, her warm water, and her voice. His mother’s voice coming from the kitchen may have seemed confusing to him. After all, he is working hard to repair a point in his very early life when he and his Mommy’s voice were truly one. He runs to the kitchen to grab it back as it was, but it is useless. Then Sam once again seeks the more reliable ‘sippy cup and bottle’ routine over the real Mommy.

Observation of Sam – Part 5 (14) At this point, I think Sam goes into his bedroom and into the bathroom and says, ‘Daye’s pooh-poohs.’ Rita laughs and says that Sam spends a lot of time in the bathroom with Daddy. She says she wonders when Sam will be ready to be trained and that at least now he tells her when he has a poop and wants to be changed. Sam comes into the bedroom, picks a shape-sorting toy, and successfully gets many of the shapes in with Rita’s help. She asks him if he wants to play with his baby couch, but he shows no interest and instead goes over to the window, closes one and tries to open another, this one without a screen. Rita tells Downloaded by [New York University] at 03:54 14 August 2016 him ‘We only open the one with the screen,’ and she reopens the first window. Sam points outside and says, ‘Truck,’ and indeed there is one parked outside. He takes up a crayon, looks at it and comes over and very deliberately and carefully hands it to me. I say, ‘Oh thank you.’ He walks a bit away, and then looks disturbed and says, ‘Want ba.’ I say to him, without handing it to him, ‘You can have it back.’ He does not make the effort to retrieve it but goes to the table and then hands me two more. I say thank you again. (15) While at the table, he says, ‘Bye-bye.’ He points to me with the crayon and says ‘Bye-bye,’ and I realize it is getting time for me to leave, so I play saying, ‘Bye, Sam.’ He says, ‘Bye,’ to me and I say, ‘Bye-bye Angela.’ He looks at me, Stuck between two worlds 31

registering my name and tries hard, ‘Bye-bye gela’ and seems delighted to have said it. I repeat my name and then he says, ‘Bye-bye An-ge-la’ stretching out all the syllables clearly. This was reminiscent of another day in that room when he looked at Rita, touched her breast and said, ‘Rita.’ Rita had been very touched and said, ‘Yes, you know me’ as if she was surprised that he did. However, I too in that moment was surprised that Sam knew me. Sam said, ‘Bye-bye’ one more time and then came over to me and threw a truck at me with great force. He repeated this two more times and his mother slightly reprimanded him. I just gave him a bit of a stern look and said ‘Ow’ softly. He went into the other room and I heard him moaning very slightly on the floor as if he himself had been hurt. When Rita got up to check on him, I followed and he was on the phone saying, ‘Daye …’ talking in a hurt sort of tone that then went to a song-like ‘daye-daye-daye.’ When Rita approached him and spoke to him softly that he was talking to Daddy on Daddy’s phone, he threw the phone down hard and went into the kitchen.

Discussion Now that Sam has his emotions defensively under control with his bottle/breast and sippy cup, he goes aimlessly about the house and happens upon the bathroom, a place where he connects with his Daddy. I believe that the memory of his strong connection with his father allows him to take the bottle out of his mouth and speak. He says, ‘Daye’s pooh-poohs.’ The part-object invocation might also indicate the anal world that Sam must live in at times, through the control he must exert on his objects, a world which does not allow for comings and goings, being hidden and being found. If instead Sam had somehow invoked the father vs. his pooh-poohs, Sam might have felt that he missed him too much. Sam passes from the bathroom into the bedroom, where he happens on a sorting toy. His mother is now by his side and she helps him, perhaps renewing for him a sense of mastery over his feelings. Rita asks him if he wants to play with his couch. The couch is a game that the two of them play where Sam is ‘rolled into’ a small child’s futon couch and altogether hidden. Mom stays by his side and keeps asking if and when he wants to come out. Rita may have invoked the couch game as a way of dealing both with her and Sam’s earlier distress. Instead of Mom ‘gone missing,’ Sam is made to disappear Downloaded by [New York University] at 03:54 14 August 2016 with Mom right by his side, and this is something he can handle. It also seems to be an attempt to repair the original trauma by putting Sam ‘back in’ to Mom’s body. Towels also are used for this purpose as Sam has always insisted on spend- ing a great deal of time wrapped up in a towel after his bath. (For a more complete discussion of these phenomena, see Sowa 2002.) But Sam at this moment is more interested in outside than inside, and he points to the window. Going to the window Sam notices a truck outside. This is the first time I had an indication that Sam might even know of an outside world; however, I wasn’t sure if it were totally outside or just another naming game. Then he gives me a crayon, thus recognizing my presence, and I feel more hopeful. He wants it back. 32 Angela Sowa

He has spoken two words together, ‘Want back.’ A sentence! But then he gives me two more instead of taking back the first crayon. Did he wipe out his feeling of having lost something by just repeating the first part of the act over and over? Or is he representing in his mind his Mommy, his Daddy, and himself? The bottle is still in and out of his mouth in this play. Sam is aware that my time with him is coming to an end and starts to play at Good-bye, maybe to have some control over my leaving. Here we have a meaningful interchange as he tries for the first time to say my name. He puts his whole body into it, leaning forward and speaking, ‘Bye, bye An-ge-la.’ I think the truck was thrown at me forcefully at the time that some feeling toward me arose in connection with my leaving. ‘Bye-bye, Angela’ means coping with both my presence and my absence, which could have been too much for the moment. Indeed, that proves true as he goes to another room pretending by moaning that he himself is the one who was struck. He invokes Daddy once again, calling him on the phone. His mother’s attempts to soothe him are met with an act of temper as he throws down the phone and leaves the room. Sam may have wanted to get rid of the emotional pain of my impending separation from him – I am now a bad object – by attempting to contact a good object, his Daddy. In the bathroom and in the play with the crayons, an early Oedipal drama may have also been invoked. He may have felt the pressure not only of a primal scene, but also of having to live in a shared world expressed by thoughts of multiples: Mom, Dad, and me and the sharing of the crayons with me. Daddy’s pooh-poohs, like his own, are also productions from inside and possibly babies, thus invoking rivalrous feelings – the tantrum being the result.

Observation of Sam – Part 6 (16) Rita sits down in the living room and I decide to stay with her, thinking Sam may have wanted to be left alone. Rita and I talk about her new shutters, and then Sam comes in, covered with shampoo on his face. He is carrying a large butcher knife. I am at the entrance of the living room and he comes toward me and touches his face very gently as if I should notice what had happened. He is holding the knife carefully and standing perfectly still. Rita comes over slowly and takes it from him and asks him where he got it. Then she smells the shampoo. Downloaded by [New York University] at 03:54 14 August 2016 (17) In the kitchen, we find shampoo all over the floor. It is so slippery that Sam fell down as if on ice (hitting the floor hard) and, instead of crying, started to cackle wildly. When he wipes his face, however, the shampoo burns his eyes and he starts to cry. Rita washes the shampoo off his hands. Sam becomes frantic trapped by all the shampoo on his face, feet, and hands. He falls again and cackles in a way that sounds eerie. Rita places him away from the soapy section and she proceeds to clean it up. Sam then plays at falling, repeating the incident. His laugh becomes less frantic. (18) By now, it is time for me to leave. I say ‘Bye-bye’ and Sam says ‘Bye,’ and just as I was at the door he says ‘Bye-bye la.’ Rita is absolutely startled by Stuck between two worlds 33

this, as I am as well. I turn around with a big smile and say goodbye again, but Sam just looks at me in a frozen state. He pushes the carriage indicating that he wants to go outside. Rita says, ‘Not now, Sam,’ and she asks if I would come next week at the time his occupational therapist would be there.

Discussion Perhaps I did not follow Sam into the kitchen because I was hurt that he threw the truck at me with such force. Certainly I was startled and unsure about how to react, as his mother did not firmly reprimand him. But I also felt sorry for Rita, and it seemed that she also needed to turn away for the moment. She wanted to show me her new wooden window shutters, a symbol to her that her life was getting at least a little bit more normal. I knew she was excited about this purchase and it had taken a long time for them to arrive. Sam was in trouble in the kitchen and he returns with an escalation that neither of us could have predicted. Even Sam seems to have been aware of the danger as he stood there utterly still, knife in hand. When the knife is safely out of hand, Sam cackles with a delayed reaction, slipping and sliding in ways that still seemed potentially dangerous from the perspective of a hard fall. His reactions felt dissociative. At the moment of feeling the shampoo burning his eyes, he becomes more aware of his body even if only on a sensate level. Sam becomes frantic, trapped by the shampoo in spite of his mother’s gentle handling. Mother is steady with her handling. It takes several minutes, but Sam, relieved by his mother of his danger, calms, eventually de-escalating and transforming his behavior into something that was more like playing at falling. The transformation from ‘cackling wildly with anxiety’ to ‘playing at falling’ is very quick, and I remember feeling confused about the quick transformation. What did Sam have in mind when combining shampoo and knife? Perhaps he was once again invoking the father ‘who shaves in the morning’ to help him with the feelings emerging as a result of giving up the claustrum (Meltzer 1992) of the bottle/breast. But side by side with identification with his father is the feeling that Daddy is not here now and, more, that Daddy stands in for someone ‘essentially’ other. Saying goodbye may have also invoked feelings of separation that resulted Downloaded by [New York University] at 03:54 14 August 2016 in launching the truck at me. This is the first time that Sam says goodbye to me using my name. Does he have any idea of how much took place in an hour of time? I sense that his mother does as she asks me to come at the time next week when his occupational therapist will be there, hoping that the two of us might exchange some thoughts.

Concluding thoughts In the hour described, Sam has acted out several scenarios that demonstrate the use of autistic defenses. But he has also been courageous, attempting to break 34 Angela Sowa

through these defenses, making use of both mother and me, sometimes succeeding, sometimes failing, dependent both on mother’s availability for mental containment and his own developmental capacity and/or limitation. Sam has truly lived part of his very early life stuck between two worlds. The pain and suffering that he experienced in the NICU, combined with the prolonged separation from his parents and the limited capacities of his immature fetal-infant mind, forced Sam to limit his world and his exchanges with other humans, particularly with his mother, to the most predictable of sorts, thereby further stifling his development both mentally and psychologically. However, his parents continued to work with him and held out hope. The separations from which Sam suffered began in the NICU, but continued through his first years of life as the parents attempted not only to reach Sam but to struggle with their own psychological barriers to parent- ing such a challenging child. It would take another two years, when Sam was around five, before his parents began to feel confident that Sam was making steady but significant progress. Development proceeded slowly and his first year at school was especially worri- some as Sam was unable to follow directions and did not easily integrate with other children. The parents worked hard to get Sam accepted into a special school that emphasized the environment and Sam began to develop a keen interest in fish, bugs, and, once again, water. Sam is now eleven years old, a verbally competent and physically active boy interested in science and the environment, acting, and Shakespeare. He has acquired his parents’ dry sense of humor and together with his mother they sing and play their guitars. He has a good memory for detail and can now make use of his curious interests to make emotional contact. He is also capable of making and keeping friends at school. His drawings remain quite primitive and there are demonstrations of a lack of hand and eye coordination. He is receiving speech therapy for diction. I would like to conclude with a dream that the mother felt compelled to tell me that demonstrates the importance of her own psychological work to Sam’s development:

I dreamt that I was pregnant again. I was about three months along, and the doctor told me that I could put Sam back in if I wanted. That way he could Downloaded by [New York University] at 03:54 14 August 2016 have the experience with this baby of staying inside for nine months. The other baby was a see-through baby – transparent. I thought about the possibility and was conflicted. On the one hand, Sam would have a chance to stay inside of me and be born normally. On the other, I would miss him terribly. The doctor assured me that he would monitor Sam through a cord.

The dream represents the mother’s very deep work of trying to come into contact with ‘the Sam that she has’. The position of the father is also emphasized through the implication of a primal scene, the ability to conceive a healthy child, and finally through the aid of a male figure (the doctor) in bringing this pregnancy to Stuck between two worlds 35

term. Though Sam’s father played an important role in Sam’s life, the dream represents the mother’s internal state, that is her ability to hold, give birth to, and then relate to her son.

The contributions of Tustin’s work I wrote this hour of observation many years ago. However, it was only later that I became acquainted with the contributions of Frances Tustin, which then allowed me to see this material through yet another lens. As I stated in my introduction, trying to categorize extremely premature infants as ‘normal or pathological’ might blur our understanding of what is as yet beyond our intellectual comprehension as it represents a brave new world, especially in regard to long-term psychological outcome. For these infants, the use of an autistic defense, as we have come to know it through Tustin’s work, does not always represent a pathological state. Instead it may be a necessary, albeit temporary solution for an infant who must withdraw from the active and taxing work of becoming more related to the world. Parents and caregivers need to be aware and respectful of the maturational limitations of the extremely immature, that is on the one hand these infants need stimulation and contact and, on the other, they suffer from being overstimu- lated. This makes even the normal cross-modal communications of mother and infant difficult to achieve. Given their profound difficulties with sensory integration, they appear to be living at times in a flat, one-dimensional world. Even with mother’s help, such a temporarily compromised infant does not have access to an ever-evolving symbolic world of meaning, a world where information coming from the senses is perceived and ultimately given dimension and complexity within a relational matrix. Instead the products of the mind can be felt to be persecutory products, a stimulus scramble, that confuses more than it explains. Given the body memories of the hospital environment, human contact can be experienced as annihilating (vs. demanding or exploitative) and the response might be of two sorts: to be glum and utterly silent or to cry relentlessly being ultimately inconsolable and unable to make use of affection and love. At the core, I believe the dilemma of the premature infant is the uncanny placement of trauma in the realm of differentiation of ‘inside/outside’. The caesura of birth assumes an infant ‘capable of being born’, even though early states of mind Downloaded by [New York University] at 03:54 14 August 2016 are still somewhat fluid. The extremely premature infant is not born but nearly annihilated by a demand (both internal and external) to survive. What this implies is that all of its being must be relegated to survival, at great cost to both physical and psychological development. What follows then is great difficulty in the ability to differentiate the painful from the pleasurable, as well as to discern the origins (inside/outside) of such sensations and experiences. In the case I have presented, Sam was allowed to live for an extended period of time in a state of illusion, where inside and outside were not so clearly delineated and where demands on him ‘to know’ and ‘to relate’ were gently titrated. His withdrawals from contact were accepted by his parents, though not without 36 Angela Sowa

consequences to their own feelings of competency, resulting at times in a mutual withdrawal, creating a screen from more troubling contact. However, even in a state hidden away in a closet or engaged in a routine, Sam needed his parents to stay in touch enough to notice when he was ready and able to be rescued. Whatever nature these withdrawals took, they were attempts to cope with, on the one hand, immaturity and on the other, psychological trauma that continued to be enacted. The trauma of being hospitalized is of a twofold nature, first and foremost that of having been separated from mother and father and secondarily of being prodded and intruded upon – and all of this without any other experience on which to base life outside the womb. Given Tustin’s writings, I think she would concur that we must travel a bit with these infants to understand them further, for we still do not know about their idiosyncratic worlds, which sometimes protect them and at other times threaten to cut them off from relationships and thus a world of shared meanings. Yet they desperately need the experience of pleasure and of trust that evolves when life is felt to be protected and contained by someone recognized as a reliable figure, bigger and more flexible than any object, routine, or rhythm. Only then can they develop their own capacities for experiencing and being impacted by the feelings of others, thereby becoming capable of love and desire. Eventually they may be able to articulate, for themselves and for others, something in language or in art expressing their own very complex beginnings, rendering yet another version of the story of ‘coming to be’. Downloaded by [New York University] at 03:54 14 August 2016 Chapter 3 Prenatal trauma and autism1

Suzanne Maiello

Introduction Human beings seem to have a primary need and capacity for meeting the ‘other’ and creating links. Trevarthen (1979) refers to this phenomenon as ‘primary intersubjectivity’ and describes it as ‘our innate sympathy for the feelings and interests of other persons’ (Trevarthen et al. 1996). Autistic children lack this primordial search for communication. What has gone wrong, and at what point? And what are the reasons for autistic retreat? Shortly before her death, Tustin (1994b) acknowledged the complexity of the processes that lead to the development of autistic states and suggested in the preface to the second edition of Autistic Barriers in Neurotic Patients (1986b) that the term ‘psychogenic autism’, which she had previously used to describe children who had been assessed as not brain-damaged, be changed to ‘psychobiological autism’. By doing so, she not only recognized the contributions of other disciplines, such as genetics, biochemistry, and neuroscience, for a deeper understanding of the genesis of autistic pathology, but also reaffirmed implicitly that nature and nurture are interwoven from the very beginning, and that the further we go backwards in time towards the origins of life, the less it is possible to separate the physical and the psychic aspects of events. Tustin in fact refers to autistic encapsulation as a ‘psycho-physical protective reaction rather than a psychodynamic defense mechanism’ (1990a: 154). With this definition she underlines the precocity of the onset of pathology. The earlier in development a Downloaded by [New York University] at 03:54 14 August 2016 traumatic event occurs, the more any protective reaction will be rooted in the body and the senses. On the other hand, it is equally true that from the moment of the first appearance of protomental activity,every physical event has its psychic counterpart. This is why we cannot exclude that even prenatal experiences can re-emerge in some form in later life. Although Tustin (1990a) never went into the question more systematically, she attributed the mental state of children who were born autistic to prenatal ‘aversion reactions’ (p. 87). Her clinical experience led her to assert that some children ‘seem to have suffered disturbances in utero, and so are born prone to be autistic even from birth’ (1986a: 98). She was struck by the frequency with which these 38 Suzanne Maiello

patients evoked a watery medium and expressed psycho-physical states in terms of liquidity, which could be assimilated to the prenatal situation. I would add that the experience of ‘freezing’ to which these patients refer when they become capable of describing their sensations of autistic isolation could represent their reaction to the terror of falling at a time when the sense of existence still had a liquid quality. Freezing is a liquid’s way of becoming a solid body. Its solidity, however, is precarious, because it cannot rely on an internal structure to ensure the maintenance of its state, but is at the mercy of environmental conditions. Beside the idea of autistic retreat being a possibly prenatal psycho-physical protection, Tustin considered autism as ‘a reaction that is specific to trauma’ (1994c: 14). Trauma can have both external and internal origins, but in both cases it leads to what she described as these children’s ‘traumatic awareness of bodily separateness from the mother … before their psychic apparatus was ready to take the strain’ (1986b: 23). Whose trauma is it? The earlier it occurs, the more physical and psychic states are in near-at-one-ness, and the more the psycho-physical existences of fetus and mother are interwoven. Tustin stated that traumatic events during pregnancy or around delivery in the lives of the future autistic children’s mothers could have an impact on the child’s psychic development and reported that all the mothers of her autistic patients had been clinically depressed before or after the birth of their babies (1986a, 1990a). These are the three strands of Tustin’s thinking which I shall pursue in the clinical part of this chapter: the idea of both a prenatal and traumatic origin of autistic retreat, and its close connection with maternal emotional and mental states.

Traumatic prenatal events The most direct threat to the unborn child’s physical survival is the danger of miscarriage. It manifests itself by contractions of the uterus which can entail a premature opening of the cervix aiming at the expulsion of the embryo or fetus. The fetus, being in contact with the walls of the uterus, will feel the contractions directly, and at the same time be exposed, like the embryo, to an increased pressure of the amniotic liquid on its body surface. In both cases, the child is liable to have uncontrollable tactile perceptions which differ from the normal situation. Downloaded by [New York University] at 03:54 14 August 2016 The threat of miscarriage inevitably has an impact on the mother’s emotional state. We know that the fetus reacts to the biochemical changes which occur in the maternal organism in correspondence with the fluctuation of her emotional states. Rosenfeld describes the unborn child’s impotence in the presence of their ‘osmotic pressure’ (1987). Every physical event in the mother’s existence has its emotional counterpart, and both seem to have an impact on the fetus’s psycho- physical state. Any unforeseen event which causes a sensation of helplessness brings about a reaction of flight and retreat. The fetus which is threatened by miscarriage may have alarming sensations which are elicited by a combination of tactile and Prenatal trauma and autism 39

biochemical elements. This may influence the child’s further prenatal and later postnatal behavior as described by Piontelli’s observational study (1992). Incidentally, it is striking to note how many mothers of seriously disturbed children had a threat of miscarriage during pregnancy. However, I would like to extend the notion of trauma and consider as traumatic not only events which disrupt an existing external or internal configuration at a certain point in time, but also include factors which impinge in a more subtle and continuous way on mental development, either through their depriving absence or their damaging presence. It is difficult to assess the potentially traumatic impact on the unborn child of temporary emotional distress or pathological mental states in the pregnant mother. The fetus is receptive to them, but the degree of their traumatic effect seems to vary from child to child. Infant observation teaches us how differently babies react to frustrating situations. It is tenable that individual differences exist also before birth. Grotstein’s (1983) suggestion that maternal depression during pregnancy could have the effect of a biochemical assault upon the unborn child in the ‘amniotic bath’ is supported by Tustin’s finding of the consistency of depression around the time of birth of their babies in the mothers of her autistic patients. Knowing that the fetus actively listens to the mother’s voice and reacts to it (De Casper and Spence 1986; Masakowski and Fifer 1994; Moon and Fifer 1990; Spence and De Casper 1987), it is probable that the unborn child receives clues of her state of mind also at the vocal level. A depressed mother’s voice will have a flatter melodious line, a slower rhythm, a weaker tone and a lower pitch than the voice of a non-depressed mother. In normal circumstances, the maternal voice has a stimulating effect on the fetus (Tomatis 1981) and may, as I have suggested elsewhere, represent an essential factor in the onset of fetal protomental activity (Maiello 1995). A low-keyed maternal voice may well have a different impact on the child’s prenatal experience.

Imagining traumatic prenatal experiences The fact that during prenatal life the child’s reactions to an event cannot be observed in a continuous way represents a difficulty if we want to think about Downloaded by [New York University] at 03:54 14 August 2016 fetal experiences. After birth, the infant can be seen, heard, and touched, and its responses give the observer immediate clues as to how he is affected by an event. Fetal reactions can be observed only for a limited time with ultrasound exploration. The only means we have in order to gain some understanding of prenatal experiences, both in normal and pathological development, is sensitive and cautious inference from clinical and dream material or from infant observation. Normal infants look and listen actively and show an immediate capacity for ‘grasping’ the environment and coordinating sensual information and responses. They create links. Autistic children avoid looking at people and do not listen, to 40 Suzanne Maiello

the point that they may seem deaf. If touched, they either withdraw or merge with the other person’s body. Before trying to imagine what the quality of a fetus’s traumatic experience might be, I would like to think about the intrinsic differences between tactile and auditory modes of perception in normal development (Maiello 1997), in order to understand what happens to their functioning in the case of the most extreme protective reaction to a traumatic event, namely autistic retreat. Touch and hearing are the main sensuous channels through which the fetus establishes contact with its environment. Although they are likely to become ‘clusters of sensations’ (Tustin 1981) in prenatal experience, tactile and auditory perceptions will be discussed separately for a fuller understanding of their functional specificity. Touch conveys a concrete ‘no-distance’ experience around the quality of surfaces. It is essentially linked with two-dimensional perceptions. If we extend Ogden’s (1989a) concept of the ‘autistic contiguous position’ to prenatal life, tactile sensations may bring about the first fleeting perceptions of bodily boundaries in normal development. Hearing, on the other hand, is an immaterial ‘long-distance mode of perception’ (Tustin 1990a: 51). It may represent a bridge between two-dimensional tactile perceptions and the first flickers of fetal ‘protomental activity’ (Mancia 1981). The mother’s voice comes from outside and penetrates into the ear. Although the vibratory component of sound may be associated with tactile sensations, there is more potential third-ness in hearing than in touch. Hearing may in fact lead the way to the first psychic proto-introjective experiences. Spensley (1995: 125) writes: ‘Listening … means taking something in, aurally and psychologically.’ The ear is an exclusively receiving organ. It is dependent on incoming sounds and has no active functional autonomy of its own. It is only after birth, with the first cry, that the infant acquires the capacity to produce sounds himself and to use his voice and mouth to initiate contact at sound level and create autonomously a sensation of vocal fullness. The unborn child’s only means of active exploration is its motility, through which it makes contact with the environment and its own body. At the auditory level, the fetus has no means to either recreate the presence of the maternal voice or to influence its emotional quality. Downloaded by [New York University] at 03:54 14 August 2016 Another difference between touch and (after birth) sight on the one hand and hearing on the other becomes significant in the presence of objects or sounds which are experienced as disturbing or intrusive. We can withdraw our hand or close our eyes in front of an object which we do not want to touch or see. If the infant refuses the breast, he will keep his mouth closed or turn his head away. At the auditory level, there is no comparable possibility of active avoidance. We have no ‘ear-lids’ to shut out disturbing sounds, neither after nor before birth. In a traumatic prenatal situation such as a threat of miscarriage, the priority of concrete physical survival may overtake other more immaterial needs. The autistic-born infant may have been induced by catastrophic sensations of Prenatal trauma and autism 41

helplessness to retreat from a threatening environment with the ensuing breakdown of the very ‘outposts’ of protomental activity. The effect of this aversion reaction could be that of remaining in or returning to an asymbolic state of ‘unmentalized experience’ (Mitrani 1992). In dimensional terms, this would mean that the breakdown of the ‘long-distance’ sense of hearing with its potential for symbol-promoting three-dimensional mental functioning could bring about the infant’s clinging to surfaces in a two-dimensional tactile mode which excludes the mental experience of distance and space. Tustin observed this phenomenon in autistic children and writes: ‘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’ (1986a: 145). If the fetus’s or the infant’s traumatic experience is not caused by a specific event but is, rather, connected with the mother’s emotional or mental state, the situation is even more complex. By what means does a normal child manage not to be affected by the mother’s distress or pathological mental state, at least not to the point of resorting to autistic self-protection? Can we hypothesize the existence of some form of a prenatal protomental precursor of the ‘contact barrier’ (Bion 1962b) with a filter function, in analogy to the role of the placenta at the physical level? We know that although the mothers of Tustin’s autistic patients were all depressed, not all children of depressed mothers escape into autistic isolation. In children who are born with autism there may have been a deficit of this prenatal ‘protomental filter’ resulting in their being exposed even more helplessly to the osmotic pressure of the maternal emotional and mental state. From the point of view of prenatal auditory experience, a distressed or mentally disturbed mother’s voice may not give the unborn child sufficient emotionally enliv- ening or alpha-element containing nourishment and may emit instead unemotional or undigested vocal beta-elements (Bion 1962b). The future autistic child may have protected himself massively from the impingement of such intolerable contents by ‘unlinking’ his hearing capacity at a deep psycho-physical level, with the effect of it losing its bridging function towards pre-symbolic mental development. Elimination of auditory receptivity could result in the lack of, or damage to, the prenatal ‘sound-object’ which in normal development seems to be nourished by proto-introjections of the maternal voice, and which seems to function as a precursor of the postnatal maternal object (Maiello 1995). Could the absence of Downloaded by [New York University] at 03:54 14 August 2016 this link be among the reasons why some autistic-born children seem not to ‘recognize’ the breast and take to it? I suggest that the later vicious circle of an isolated child and a mother hesitant in soliciting a response might have a prenatal precursor in the mother’s distressed emotional or disturbed mental state as it reveals itself in her voice and the fetus’s auditory retreat.

Rosetta’s prenatal trauma: early history Rosetta was a five-year-old only child with severe autistic features when she was referred for psychotherapy. Before her birth, the mother had ‘several 42 Suzanne Maiello

miscarriages,’ as she put it when we first met. Tustin states that among her autistic patients’ depressed mothers, some ‘had 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’ (1986a: 95). When the mother was pregnant with Rosetta, there was again a threat of miscarriage at five months gestation. A cervical ring was placed and saved the baby’s life. The delivery was at term without complications. Rosetta was breast- fed for seven months, but gaze aversion was reported from the first weeks of life. After weaning, she refused the bottle and passed directly to spoon-feeding. She did not crawl, but pulled herself to her feet at nine months and was put in a walking ring to move around. The mother fell pregnant again one month later, but had a miscarriage and lost the new baby in the fifth month. At one year, Rosetta said her first words, but there was no progress and she lost her initial capacity. When she started walking at 18 months, her mother became pregnant a second time, but again lost the baby. The doctors finally found out that her organism produced antibodies which attacked the embryos. I was alarmed not only at the thought of Rosetta being the only surviving child among a number of dead babies, but even more by the mother’s angelic smile and the lack of emotions with which she reported both Rosetta’s progress and failures and her own miscarriages. The mother saturated every moment of possible reflective silence with an uninterrupted flow of words. Her tone of voice was both high-pitched and infantile, flat and impersonal, and her speech was very inarticulate. It felt as if the words slipped almost unshaped out of her mouth and away, unseen and unheard by herself. The father did not hide his impatience and violent disappointment towards both his ‘childish’ wife, whom he tried to exclude from our ‘adult’ conversation, and his ‘retarded’ daughter. During Rosetta’s psychotherapy, his personal problems came to the fore. He drank heavily, and his behavior in the family was violent and abusive. Later, he accepted psychiatric treatment. Mother and child had never been separated since Rosetta was born. In the mother’s mind, they seemed to live in a perpetual state of ‘dual unity’. Tustin uses this term to describe the abnormal adhesive at-one-ness between mother and child which precedes autistic retreat (1994c). Downloaded by [New York University] at 03:54 14 August 2016 Rosetta’s mother and her ‘twinning’ phantasies Before the first interview with the parents, the mother surprised me by asking if her sister could participate in our meeting. When therapy had been arranged on a three-times-a-week basis, Rosetta was regularly brought to the sessions by the mother and the aunt. The two women had a striking resemblance. Perhaps the mother found it too difficult to be on her own during the child’s session. When she came to fetch her daughter, she took the five-year-old girl in her arms and carried her away as if she were a baby. Prenatal trauma and autism 43

At the beginning of therapy, the mother had wanted to fulfill what she presented as Rosetta’s wish, namely to buy her a puppy. Later, she planned to take a child of Rosetta’s age into foster care, so that her daughter would have some company. Both needs seemed to originate in herself more than in the daughter. The mother’s ‘twinning phantasies’ aimed at excluding the danger of separation and of safeguarding a condition of ongoing fusional ‘sameness.’ In thinking about a patient, Bion writes: ‘… the imaginary twin … was an expression of his inability to tolerate an object that was not entirely under his control. The function of the imaginary twin was thus to deny a reality different from himself’ (1950: 19). Before meeting Rosetta herself, a later event which involved her mother must be anticipated. One day, five months after the beginning of therapy, she brought the child to a Monday session carrying her in her arms. Rosetta’s face was swollen and heavily bruised around her eyes and nose. It was unthinkable to separate them, and the mother held Rosetta on her lap for the whole session. During a walk with her father, the child had fallen from a wall and had been in hospital over the weekend. A few days later, the mother was to tell me that she was pregnant again. She then interrupted her own therapy which had been arranged with another therapist from the beginning of the child’s treatment. I did not feel that she had fled into this new pregnancy to escape a feeling of emptiness, which would have presupposed some perception of a three-dimensional inner space, but rather that the idea of a new baby was another realization of her adhesive ‘twinning’ phantasy, which she had so far realized in the mutually clinging at-oneness with Rosetta. The mother intuited that the quality of their relationship would change as the child’s psychotherapy progressed. Incidentally, the timing of the two preceding pregnancies followed by miscarriages is striking if it is seen in relation with Rosetta’s early developmental stages. The first pregnancy had begun shortly after Rosetta had learnt to stand on her own feet, and the second shortly after she had started walking. The mother’s flat substanceless body seemed the specular material counterpart of her mental state. I was deeply worried by the idea of the absence of both physical and mental space for a new baby inside her. I also feared that Rosetta’s treatment might be in danger. Two more miscarriages lay in the air. The family did manage to keep their commitment to Rosetta’s treatment, but at the end of the sixth month of pregnancy, in the middle of the summer break, Downloaded by [New York University] at 03:54 14 August 2016 the mother gave premature birth to a little boy. His life was in danger for a long time, and he spent four months in an incubator. When the mother brought Rosetta back to therapy after the holidays, I expected to see a woman in her seventh month of pregnancy. Instead, she pointed to her flat body and said, with her angelic smile ‘the tummy is gone,’ leaving me for the whole first session with Rosetta after the long separation with the doubt whether the baby was alive or dead. The parents told me later that there had been a threat of premature birth, and the attempt to place a cervical ring had failed. They had not told Rosetta anything about her little brother, because they feared that she might be traumatized if he 44 Suzanne Maiello

died. Another child was in danger of slipping away unseen and unheard like the preceding unborn babies.

Meeting Rosetta Rosetta was a graceful little girl. Her hair was gathered in two pigtails at the sides of her head. When I first saw her, she wore two elaborate long ear-clips, obviously her mother’s, which dangled on her shoulders and gave her an incongruous look. From the beginning, there were brief moments when she looked at me with her wide eyes and also seemed to listen to what I said. But most of the time, she had one of two mask-like expressions on her face, with the corners of her mouth pulled either upwards in a radiant smile very similar to her mother’s, or down- wards to make her look gloomy and withdrawn. Both masks protected her from emotional contact. By alternating the two expressions in rapid sequence, any potential communicative meaning was further confused. Her language was mostly echolalic, but after I had presented some toy animals to her, she named some of them. She found the cow, looked for the calf, touched the cow’s udder and said ‘milk’ with an almost inaudible voice. Also, her speech was so inarticulate that the words often disappeared before I could pick up their sound and work out their meaning. I felt induced to speak like her, in an almost voiceless whisper, as if the idea that there could be a dialogue had to remain unseen and unknown by both of us. When manipulating the animals, she had touched and looked into their mouths, especially the crocodile’s. Were the teeth dangerous? I remembered that Rosetta had refused the bottle as a substitute for the breast. Or did the danger lie in the voice and in verbal language? There were moments of intensely aggressive action. She violently bent back the legs of the toy horse (I heard later that the mother was a passionate horse- woman) and banged the cow’s head on the figure of a lamb lying down. Or she clutched a toy animal tightly in her hand, pressed her lips together and ground her teeth. There was more to her violent clutching than the need to merge with an autistic object. Other aspects of Rosetta’s behavior had a more autistic quality. The immobility of objects was so important that sitting down at her little table was difficult. Downloaded by [New York University] at 03:54 14 August 2016 The chair had to remain stuck to the floor, and she could hardly slip herself into the narrow space. Rosetta’s assessment showed that she did present severe autistic features, but there had also been more hopeful moments of either persecutory phantasies or fleeting communications.

Liquidity: rain and tears When she became less isolated, Rosetta showed me her need for physical containment. She would ask me to make ‘the little house’. Her low table had to be Prenatal trauma and autism 45

covered with the blanket. She would crawl underneath, and crouching in there would talk in almost inaudible fleeting whispers. If I wanted to grasp any of her words, I had to bend down and put my ear to the blanket. Sometimes, a little dialogue developed, but more often I was unable to catch anything of what she said, and no contact could be established. Usually, she entered her little house because it rained, but the house did not seem to offer adequate shelter. It always rained inside as well. Sometimes Rosetta cried, but when she did so, she was not in contact with any felt pain. To her, crying seemed to be something like coughing or having a hiccup, and she called her tears ‘drops on my cheeks’. She seemed not to know about the link between her anguish and distress and the tears. I was reminded of the emotionless voice with which her mother had reported the dramatic events before and after Rosetta’s birth. The mother was struck when she heard her daughter use the word ‘crying’ spontaneously for the first time. Rosetta did so when one of the mother’s sisters was pregnant. Putting her ear to her aunt’s body, she said: ‘The baby is crying.’ In listening to this unborn child, the drops on her cheeks and the rain that used to fall into her little house in the session seemed to have become meaningful tears. A new-born baby cries when he is in distress. Through crying, he evacuates unbearable strain and at the same time he signals his need to the environment. But the fetus is voiceless and totally impotent.

Tactile sensations and panic Rosetta often insisted on wearing a pair of tights on her head, with the leg-part hanging down on both sides of her shoulders. While the pant-part and the elastic seemed to have a containing function, the hanging leg-part excited her. It was related to the softness of the mother’s long hair, and also to the dangling ear-rings which Rosetta had worn when I first met her. They all belonged to the same area of eroticized sensuousness which united mother and child. However, this mental state usually broke down very soon and revealed the underlying uncontrollable terror of annihilation. Rosetta would urge me, in a state of rapidly escalating panic, to tie a string around her head or fix something better, but she was unable to explain what I could do to help her, and my attempts to give her a feeling of Downloaded by [New York University] at 03:54 14 August 2016 being safely held almost invariably failed. There seemed to be nothing I could do but share her feeling of total impotence. Rosetta’s pigtails had a similar protective function. They were fixed with round elastics. When she was anxious, she felt them to be loose. She would first try to fasten them herself, usually without success, and then, as her terror intensified, I had to intervene. On other occasions, she pulled off the elastics of the pigtails and let her hair flow freely. She would shake her head and wrap herself in its sensuous and exciting softness. But then the anxiety inevitably came back. In her panic of falling and spilling away, she wet her pants, and I had to do her pigtails again and fasten 46 Suzanne Maiello

the elastics as tightly as I could. This usually happened towards the end of the session. At a later stage of therapy, her request to tighten them was accompanied by her saying with a sense of urgency: ‘I want mummy.’ We know that the cervical ring, the function of which was to close the mother’s prematurely loosening uterine sac, saved Rosetta’s life. It was, perhaps, my perception of Rosetta’s liquid mental state, together with the paroxysmal quality of her panic, and her total inability to show me what I could do to hold her together, that made me think of the utter helplessness of the fetus when there is a threat of miscarriage. It is a matter of life and death, and there is nothing the fetus can do about it.

Rosetta’s three voices The vocal register which Rosetta used most frequently at the beginning of therapy had an artificial high pitch, similar to the mother’s and the aunt’s voices. I knew that she watched cartoons on TV for hours. When she was echolalically adhesive to her cartoon characters, her speech was clear and articulate, pronouns and verbs were used correctly, but she was inaccessible to any verbal exchange with me and placed her odd pseudo-adult stereotyped sentences here and there to create a sound pattern that resembled a dialogue but was totally artificial. When she did so, she usually wore her expressionless ‘smiling mask’, with the corners of her mouth showing upwards. When she sang the melodies of her favorite video stories, it was as if she dissolved in their musical shapes. Rosetta’s own personal voice had been little more than a fleeting whisper at the beginning, and I had to be very alert to catch what she said. Often I only got the soundtrack of her communication which I ‘incubated’ silently within myself, trying to imagine what she could possibly have said in the context of the moment, until, hopefully, the rhythm and melody of her communication released a possible meaning. As the therapy proceeded, her voice became louder and more confident, but her speech remained blurred and inarticulate, very similar to her mother’s. There was a liquid quality to Rosetta’s language just as with her whole being. It was as if her words too had remained immersed in a musical continuity and had not acquired the structural autonomy, which is necessary for them to have a neat sound-shape and to form meaningful links between each other. This development Downloaded by [New York University] at 03:54 14 August 2016 can take place, both in thinking and consequently in language, only if the process of separation has not been arrested at a very early stage. Rosetta was able to articulate clearly as long as she was in echolalic adhesive at-oneness with the TV voices, but when it came to her own voice, the anxiety connected with the perception of her separateness seemed to be too intense, and the words remained agglomerated in indistinct clusters. Much later, during the third year of therapy, the parents told me about Rosetta’s ongoing primary nocturnal enuresis. Once more, the fact itself struck me less than the belated and mindless way in which they told me. They had never thought about the direct and obvious relation between the great quantities of water Prenatal trauma and autism 47

Rosetta used to drink before bedtime and her bedwetting. Here again, the problem of setting limits was the issue, and there had been an unconscious collusion of the mother with the absence of Rosetta’s sphincter control. After a few months, she was dry. Much to the parents’ surprise, her speech simultaneously became clearer and more articulate. A similar phenomenon of clustering occurred in the time sequence of our verbal interaction. In a normal dialogue, two speakers talk and listen alternately, according to a rhythmical pattern of reciprocity. With Rosetta, it happened that when we had been silent for a while, she would start speaking at exactly the same moment as I did. I would stop immediately, in order to hear what she was saying, but she would stop as well. I would then wait for her to speak again and listen. If she remained silent, at some point I would try to say something about my wanting to hear what she was telling me, but she would start speaking again the very moment I did, and once more I could not hear what she said. The absence of rhythmical alternation had the effect of non-communication. It was as if we were both deaf, and in a way also mute. In echolalic speech separateness is obliterated by the adhesive sameness of verbal productions. In our situation the potential dialogue broke down into an indistinct cluster of words because the pattern of reciprocity that develops in time had collapsed. There was a temporal no-distance situation. Two voices coincided and annihilated each other, and two pairs of ears were made useless. Reciprocity begins where fusion ends. If, during prenatal life, tactile no-distance sensations shut out the normal auditory experience of the mother’s coming and going voice then, I suggest, the fetus might miss out on basic temporal and, in particular, rhythmic experiences which lay the ground for the later capacity for reciprocity which finds its first active postnatal expression in the cooperative rhythm between the sucking mouth and the milk flow of the breast. At some point, the alternation of Rosetta’s echolalic cartoon voice and her personal timid, blurred whisper was interrupted by a third voice, which broke forth unexpectedly and dramatically. There was an outburst of non-verbal sounds and vocal noises of overwhelming power and with an archaic, primordial quality. They evoked the roaring, moaning, and howling of wild animals. In those moments, usually at the beginning of the session, the little girl stood upright in front of me, looked straight in my face while producing the powerful sounds Downloaded by [New York University] at 03:54 14 August 2016 which came from somewhere in the depth of her being. It is not easy to describe my countertransference feelings. Her ‘jungle voice’ was not mad, not frightening, not aggressive, it just was. A powerful self-affirming sound-presence. Sometimes, Rosetta would close the shutters and roar in the dark. After she had evoked and imitated animal sounds for some time, she started naming wild animals such as black panthers, sharks, and crocodiles, and expressing feelings that were related to oral aggression. Gradually, her vocal productions got closer to the human world. Pointing an imaginary gun in my direction, Rosetta emitted the sounds of shooting. Another transformation of the animals’ voices was their turning into the voice of a witch. On those occasions, Rosetta started 48 Suzanne Maiello

screaming in a frightening crescendo. At its highest pitch, her voice became an almost unbearable ear-piercing shriek. The first time, she stopped all of a sudden, literally collapsed and went into a panic. In her anguished mumble I could make out: ‘Mummy doesn’t want, mummy is weak.’ It was important that my ears could take, contain, and survive the almost unbearably piercing sounds that Rosetta could now evacuate and project into me.

Towards the experience of a three-dimensional vocal container and the primary sound-object My feeling was that Rosetta herself perceived her first roaring outbursts as coming from within. The discovery of a primitive but strong vocal part of her self seemed to coincide with a physical experience of a three-dimensional internal space. It certainly conveyed to me a strong countertransference sensation of a vibrating volume inside her. This was in contrast to both her adhesive cartoon voice and her inarticulate whispers. The powerful new sound-base had gradually expanded over the whole scale of her vocal resources and allowed her to move forward by inventing variations to the initial archaic sounds and by attributing them to animals which she could name. This helped her to enter into contact both with her terrors and her aggressive feelings towards her mother. This evolution in the area of her vocal production had occurred during the first months of Rosetta’s therapy. Five months after we first met, she had her traumatic fall, which was followed by the session during which mother and child could not be separated. When the accident occurred, the mother herself did not know yet that she was pregnant again. During the week that followed her fall, Rosetta had moments of intense anxiety and needed to have the elastics of her pigtails tightened more often, but, strangely enough, she was more communicative, her speech was more articulate than usual, and she actively explored her vocal, preverbal, and verbal capacities. Rosetta talked swiftly and clearly and reproduced the voices of animals such as chicks, pigs, and dogs. For the cow, she produced long ‘muuuuuuuh …’s. Then she imitated gunshots and a car engine. I commented that today she was full of voices and noises inside and could let Downloaded by [New York University] at 03:54 14 August 2016 them come out, and I could hear them too. They were all different from one another. I named the animals, the gun, and the car. She ground her teeth, started yelling and screaming, let her saliva drop on the windowsill and spread it with her sleeve. I said that now she had got frightened and angry, because she was not sure any more that it was safe to know so many different voices, to let them out and give them names. By spreading her saliva, she wanted everything to become the same again, Rosetta and a Rosetta-window and a Rosetta-window-sill. She continued spitting and spreading saliva. Then she said, maybe commenting on the different sizes of her spits: ‘A big one and a little one.’ Prenatal trauma and autism 49

Amid her same-making autistic shapes, she was again noticing differences. She undid her pigtails and cut a piece of string, as if she wanted to ask me to fasten them again, but she stopped and said instead: ‘When does mummy come?’ She tried to open the door, but desisted and said instead: ‘Mummmmmmmmmm …,’ as long as her breath lasted. She repeated this many times. I said that now she was feeling full of a mummy-sound, and this helped her to feel good inside and to wait for her mother to come back. After my comment, she started singing, not her usual TV or cartoon songs, but melodies that she clearly invented on the spur of the moment. The words were also of her own invention. I could make out a few of them: ‘Kitten – cries – midnight’. The mother came to fetch her with the ‘twin’ aunt who left with Rosetta. She herself remained behind to tell me that she was pregnant. The function of the sounds, which Rosetta had produced during this session, was different from the defensive use she made of them when she wrapped herself up or dissolved in musical shapes. This time she seemed to experience her going-on-being at a sound level, with a feeling of consistency and continuity within herself, which she now had the power to reproduce vocally when she needed it. After this session, interestingly, the ‘jungle voice’ was never to appear again. New sounds seemed to have developed out of those primordial noises and were human language. They seemed to be usable as elements for building and shaping parts of what I described as a sound-object. Shortly before the summer break, the parents had not yet told Rosetta about the pregnancy, because they wanted to be reasonably sure that there would be no problems. When the mother was four months pregnant and Rosetta was still not supposed to know, she produced the following material. Rosetta lightly touched my stomach when she came in. She then asked me to help her to fasten a long piece of string around her neck and around mine. When we were tied together, she pulled me down to the floor on my hands and feet and wanted to use me as a refuge, as she usually did with the little house when it rained. She sought shelter under the arch of my body and then crawled out and got to her feet. There was a knot in the string that tied us together, halfway between her and me. She asked me to undo it and to tie her and myself to two separate hooks near the window. I made a descriptive comment about being tied together and getting out and Downloaded by [New York University] at 03:54 14 August 2016 separating and, all of a sudden, there was something wrong with her forehead, and I had to intervene in what appeared as a dramatic emergency situation requir- ing tying or holding or tightening. But none of my attempts seemed to help. She went into a panic and cried out loud: ‘It’s no good.’ She began screaming words and holding the last vowel as long as she could, in a dramatic crescendo: ‘andareeeeeeeee …’ (goooooooo …). Her whole body stiffened and she trembled all over in her tremendous muscular effort. Tears shot out of her eyes and saliva dropped from her mouth as she screamed. I tried to say something about her being terribly frightened of coming out and being on her own, but I felt that my words did not reach the roots of her panic. 50 Suzanne Maiello

She went on screaming: ‘Nell acquaaaaaaaaaa …’ (in the wateeeeeeeeeer …), and then a sequence of words that ended with ‘pozzoooooooo …’ (a water wellllll …). I said that something terrible must have happened. Had somebody fallen down into a well? Was there water in that well? I told her that I wanted to rescue this somebody and accompanied my words with the gestures of a person who pulls up a bucket on a rope from a water hole. Rosetta watched me and calmed down, and then joined me by pulling on an imaginary rope of her own. After a while I stopped and said that maybe we had pulled up this somebody now and asked her whether she was all right. She said yes and remained calm until the end of the session. Rosetta seemed to have re-experienced terrors which may have been connected not only with her birth, but also with the threat of miscarriage to which she had been exposed during her prenatal life. Many elements may have contributed to making this dramatic representation possible at that very moment. For her pregnant mother, the time of her former miscarriages was approaching. Was Rosetta still so much part of her mother mentally that she still underwent the prenatal ‘osmotic pressure’ of her phantasies and fears, although she was not supposed to know about the pregnancy? Or was she the receptacle of the mother’s split-off emotions? In other terms, did the mother’s dread of another miscarriage reach Rosetta via her mother’s projections in the here and now, or did the present situation re-evoke in her own prenatal traumatic experience of almost falling out of her mother’s womb? If she was able to relive and to represent this event now, could this be linked also with the fact that she had met her own strong primordial voice and could use it to tell me verbally about her trauma, while remaining in the trauma physically with her body stiffening in panic? The well and the water and somebody falling down reproduced her own history with amazing precision. I felt that my mental and verbal containment were insufficient and that my hands had to help, rescuing the person who had fallen down, just as at the time the cervical ring had been necessary to reinforce the maternal container and save Rosetta’s life. As to the use of her voice in this session, I think that she tried, as she had done earlier, to ensure her going-on-being vocally, but in the traumatic event that she herself had re-enacted by representing a birth situation or the threat of a miscar- Downloaded by [New York University] at 03:54 14 August 2016 riage, it was not sufficient to counteract the physical danger of falling. When exposed to the risk of miscarriage, the fetus may well react to the contractions of the uterus and to the threat of being expelled by increasing its muscular tension. Perhaps Rosetta was showing how the psycho-physical autistic shell may be the last resort when there is nothing else to cling to.

Discussion Rosetta’s history, in which traumatic events occurred during prenatal life and signs of autistic retreat were present from the beginning of postnatal life, is used Prenatal trauma and autism 51

to make a tentative connection between the child’s intrauterine experience and her pathology. The hypothesis of some form of relation does not imply a linear monocausal relationship between the two. As mentioned in the introduction, the earlier in life protective reactions occur, the more the individual is to be seen as a psycho-physical entity, and the more likely it is that genetic, biological, and neurological factors are involved in pathological development. From the psychoanalytic vertex, however, knowing that proto-forms of mental activity are present in the fetus and that the child keeps traces of memory of his pre-history, my hypothesis is that traumatic experiences may, as suggested by Tustin (1990a), lead to prenatal psycho-physical aversion reactions. This view is supported by Piontelli’s observational and psychoanalytic study (1992), which gives striking evidence of the prenatal behavioral precursors of postnatal defensive patterns. In Rosetta’s psychotherapy, three factors converged to stimulate my thinking about prenatal trauma: her mother had had a serious threat of miscarriage during the pregnancy; the little girl had severe autistic features without being totally autistic; and the mother’s new pregnancy during therapy represented a re-edition of past traumatic events. However, the threat of miscarriage, which Rosetta survived, should not let us forget the possible impact of the mother’s internal state, which had probably been aggravated by her previous unmourned miscarriages. The threat of miscarriage and the mother’s massive splitting of painful emotions can be seen as two sides of the same coin. For Rosetta’s mother, the undifferentiation of self and other was meant to protect her from unbearable separation anxieties which intensified with every miscarriage. The two-dimensionality which characterized her personality expressed itself equally at the physical and mental level. Both her body and her mind seemed to have no volume and no internal space. Her unborn babies had slipped away from her like her unthought words during our meetings. Her repeated miscarriages could be seen both as the realization of a non-containing internal object and as the model for yet another repetition of the failure of her womb to contain a child. And every failure increased the splitting off of emotions and reinforced mental adhesiveness in an endless vicious circle. It took many months after the premature birth of Rosetta’s little brother for the Downloaded by [New York University] at 03:54 14 August 2016 mother to accept resuming her own psychotherapy, for which she had never felt intimately motivated. She frequently missed sessions because she forgot about them. Her fragility was such that the rare moments of insight were followed time and again by new absences. No introjective experience seemed tolerable. Returning to Rosetta’s material, I suggest that the discovery of her own powerful voice may have broken the circle and opened the way to freeing herself from the terror-stricken adhesive closeness to her mother and to feeling the emotion of existing as an individual. I described how difficult it had been to attribute a particular emotion to her ‘jungle voice’. But it was emotion, the primary stuff that emotions are made of, and my countertransference feeling was that she was 52 Suzanne Maiello

communicating: ‘I AM.’ Here and now, Rosetta was. She was her voice. I could hear and see her, and she looked at me, saw me, and heard herself. Had she found in herself the primary emotional containment that had been missing in her prenatal experience of her mother’s womb-mind-voice? Did the ‘jungle voice’ give her the auditory-mental and the physical awareness of an inner space that could become a container of internal objects and contribute to setting in train projective and introjective processes? I suggest that meeting her voice represented the core from which she could begin to bear the reality of distance and move away from her former state of adhesive at-oneness and attempt to complete and repair her insecure original sound-object.

Conclusions The clinical material of autistic children whose mental development stopped at a very early stage in their life gives us access to a deeper understanding of the most primitive protomental processes. If the onset of a child’s self-protective reaction to a traumatic situation reaches back as far as prenatal life, his postnatal behavior gives us clues about the ‘missing links’ in the earliest processes of psycho-physical integration, which seem to be closely connected with sensuous experiences. Psychoanalytical thinking has traditionally moved from the observation of pathological phenomena to thinking about normal development. In this chapter, I followed Tustin’s view of autistic retreat being a reaction to a traumatic separation experience whose origins may in some cases reach back to prenatal life, and I gave the question of the failure of prenatal protomental processes further thought, with particular attention to auditory experiences. The chapter also illustrates Tustin’s idea that autistic retreat is connected with a pathological psycho-physical closeness in the mother-child relationship. This aspect is likely to be particularly relevant in those cases in which autism is rooted in prenatal life. The earlier pathological development begins, the less distinct the psycho-physical boundaries are between the mother and the unborn child. Referring to the fetus’s ‘protomental nucleus’, Mancia writes that ‘it is permeable to the representations that reach it from the internal world as well as to the sensory experiences that reach it from the external and maternal world’ (1981: 353). Much thought has been given to the role of the mother’s personality in the Downloaded by [New York University] at 03:54 14 August 2016 genesis of autistic pathology. Kanner described the mothers of autistic children as tending to be ‘cold and intellectual’ (1943). This view generated the term ‘refrigerator mothers’. The tendency was to see them as the cause of their children’s pathology. The ensuing counter-reaction may have shifted the ideas about the origin of autistic retreat excessively to the internal difficulties of the child. Later, Meltzer (Meltzer et al. 1975) and Tustin (1986a) recognized that it was undeniable that maternal depression was a factor that could contribute to the breakdown of the primary relationship, but they also made it clear that this does not imply that mothers are responsible for their children’s pathological development. Prenatal trauma and autism 53

In recent years, developmental psychology and infant research have contributed to the recognition of the central role of reciprocity in the development of the primary relationship, and it has become possible to explore these deep primal interdependencies without blaming the mothers, who often are themselves at risk. Kanner’s metaphor of the ‘refrigerator mothers’ is met perfectly by Tustin’s image of the ‘frozen child’. Container and contained share an experience of coldness. The mother’s internal world may be inhabited by a child who is as frozen as her external autistic child. Her mental state may be related to the burden of previous traumatic experiences that have not been worked through. These mothers need to be helped to ‘thaw’ emotionally as much as their withdrawn children. If it is true that the maternal voice may be one of the vehicles through which the fetus receives clues about the quality of maternal representations and the state of her internal world, it is likely that in situations of maternal distress or mental disorder, the fetus’s potentially traumatic experience may be connected not only with the absence of a needed ‘good object’, but also with the presence of an impinging ‘bad object’. The maternal voice-mind, and the postnatal breast-mind, may offer the same range of actual good or bad nourishing qualities and quantities. In other terms, the badness of the internal object may result not only from the infant’s intolerance to frustration. The fact that auditory experience is immaterial, as opposed to tactile perception, increases its primordial importance for the development of the fetus’s protomental activity in the direction of presymbolic openness. It is this predisposition that seems to be at risk of breakdown in a prenatal traumatic situation. Under certain conditions, the trauma may bring about the fetus’s retreat from the auditory level of experience to the more secure, concrete, no-distance tactile mode, in an extreme attempt to escape the threat of annihilation. The seemingly deaf and stiff-frozen autistic child tells the story of the impact of early traumatic experiences with the ensuing failure of primary tactile and auditory proto-integrations, which normally are likely to begin in prenatal life and can be seen as the prerequisites for the development of later three-dimensional symbolic mental functioning. Downloaded by [New York University] at 03:54 14 August 2016

Note 1. This chapter was awarded the 1st Annual Frances Tustin Memorial Prize in 1997 presented at the FT Memorial Lecture in Los Angeles on November 14, 1997. It was published in Italian as ‘Trauma prenatale e autismo,’ in Richard e Piggle, 3/98. Chapter 4 Further reflections on the construction of the body-ego1

Geneviève Haag

Throughout her work on the clinical study of autism, Frances Tustin described the severe abnormalities of the body-ego that result in the autistic shell. This was the case in the children she called ‘crustaceans’, who show a total encapsulation in this autistic shell of which she emphasized the two-dimensional nature, as well as in those children whom she called ‘segmented’ (Tustin 1981). As a corollary, at the beginning of her paper ‘The development of “I-ness”’ (Tustin 1984c), she states how this pathology exists as though ‘to demonstrate the importance of the body image in the process of becoming an “I”’ in parallel with the growth of insight into pathological mechanisms. We are learning more from children who are in the process of recovering about normal processes involved in the construction of the body-ego. This work takes place at the interface of many lines of investigation: of work with autistic children at a particular stage of their development, of infant observation, of the analysis of neurotic and borderline children and adults. Tustin (1984a) described child patients ‘who felt skinless and disembodied. The 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.’ She described an aspect of the psychotherapeutic process which I have called the ‘boucle du retour’, which means literally the ‘returning loop’, and which involves the transformation of primitive states in which drives may be experienced as water that overflows, fluids that burst out, and gases that explode. I quote: ‘As they (the autistic children) feel that the uncontrollable “waterfalls” and Downloaded by [New York University] at 03:54 14 August 2016 “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’ (Tustin 1986a: 235). The autistic children whom I have treated or whose treatment I have supervised have taught me details concerning the building or rebuilding of this containing function which are very much on the level of bodily experience (though at the same time on the level of phantasy?). My use of the term ‘containing function’ refers, of course, to the theoretical formulations of Bick and Bion. I will focus particularly on the importance of the gaze/attention for the Further reflections on the construction of the body-ego 55

integration of the tactile and auditory components in the formation of the skin, as well as for the psychological ‘ownership’ of the large axial body joints and the joints of the limbs.

Clinical material

The back, the background, the gaze, and the skin: the pivot between two- and three-dimensionality I have had experience of working with several children under the age of two who have suffered from etiologically varied developmental arrests, manifested especially in psychomotor symptoms – such as stiffening – and lack of interest in the exploration of space and objects. During their psychoanalytic sessions these children ‘explained’ to me, in a pre-verbal language, their need to find concomitantly – and within a relationship of close attention – both the tactile experience of the ‘contact of the back’ along with the mutual interpenetration of the gaze, as long as this interpenetration is a soft one. This dual experience seems to give them the sensation-feeling that something is entering deep into the inside of the other person’s head, where it imprints certain qualities and contributes to the creation of a ‘background place’ in which interrelations can unfold. This ‘background place’, an experience of a background with a floor, is instrumental in helping these children to overcome the panic and fear of exploring the depths of external space. Besides, the interpenetration of reciprocal gazes facilitates the achievement of upright posture, of a sense of verticality that becomes assimilated to the psychic vertical axis and to the constellation of ‘nipple-penis’. Bruno, a child in his second year, produced particularly clear material related to these ideas, as do many autistic children who are re-establishing eye contact in the transference. It is common at such times for the child to come very close to the therapist’s eyes, as though getting inside them, thus creating what one might call a ‘Cyclops effect’. Following this, the child quickly goes to stick himself to the back of the therapist’s head. Downloaded by [New York University] at 03:54 14 August 2016 Bruno aged 20 months I will not give the whole of the observation of Bruno (Haag 1991b); I will quote just one episode, which took place when Bruno was 20 months old, and four months after he had experienced, in relation to me, the integration of tactile sensations along his back with mutual interpenetration of the gaze. He picked up a little cube, gave me a good look, placed the cube between his eyes (as a kind of third eye perhaps?), pushed it gently up along the middle of his forehead, then backwards along the median line of his head, laid it gently along the nape of his neck and then let it slide down his back. Following this, his play 56 Geneviève Haag

with toys appeared to illustrate how when anything went wrong in this ‘space behind,’ he had the experience of everything exploding, and of having to revert to a two-dimensional, empty ‘facade’.

Laurent aged five years I will now give material from another child, Laurent, aged about five, who was severely autistic and mentally impaired. In a group setting with two therapists, he gave us a glance that was very brief, but warm and penetrating, then resolutely sat on my knee, wedging his back against me and ‘diving’ into the eyes of my colleague who was sitting facing me. He then stood up, turned round to face me, and ‘dived’ into my eyes, coming very close to producing a ‘Cyclops effect’. He walked about a little, making a modulated, ‘curving’ sort of sound, while stretching out his left arm and curving it back towards his ear in a round and graceful gesture. He repeated the sequence several times, with variations that seemed to express different emotional qualities – qualities that he had perhaps discovered in the ‘bottom-floor’ of the two therapists’ heads. In correspondence concerning this ‘bottom-floor’, Frances Tustin pointed out to me that Ogden (1989a) called it the ‘sensory floor’, while Grotstein (1980) called it a ‘psychic floor’. Two months later, just after the first holiday interruption to the rhythm of the sessions, Laurent led me to the sink, turned on the tap and remained close to the running water. He filled his mouth full of water, then spat it out as far away as he could. We spent some time wondering about this, then returned to our respective seats. He then came up to me, ‘dived’ straight into my eyes, but instead of finding a background ‘floor’, he passed very rapidly alongside me and fell down behind me, as though he had passed through my eyes but not found any ‘bottom-floor’ in my head. He conveyed the feeling that he had literally fallen through on the other side of my eyes. He then jumped up as though on springs, folding his arm very violently. This had formerly been his characteristic ritual, and he now accompanied it with a piercing shriek. Before he came to treatment, his shrieking was so unbearable that he was about to be expelled from the institution he attended. This symptom quickly improved after his early sessions. Downloaded by [New York University] at 03:54 14 August 2016 We interpreted that he had lost his ‘bottom-floor’ in our heads that stopped him from falling, so that he had recourse to clutching onto our ears by means of his piercing shrieks. He responded by repeating the initial sequence I have described. Then he walked very calmly over to trace with his finger the wavy shapes in the draining board, emphasizing the concavities, and then the similar shapes in a curtain – shapes that embody the rhythmical beginnings of a containing shape. After this session, my colleague and I felt that the floor, or bottom-floor, was more solidly established. Laurent’s gaze became stabilized and communicative outside the sessions and in his relationships with his institutional caregivers. Further reflections on the construction of the body-ego 57

I will now recapitulate some of these points with reference to material from Paul, a four-year-old boy with Kanner’s syndrome, whose language was just beginning to take off.

Paul aged four years Paul had been treated for Kanner-type autism since the age of 20 months, at which time his symptoms were typical of the syndrome. Following intensive interpretative work focused on the penetrating, aggressive/predatory, devouring and distancing aspects of eye contact, this was established very gradually between the ages of two and three and a half, when he began to produce his first sentences. Then, for a few sessions, he showed interest in two small, almost similar, oval-shaped containers. This similarity (likeness rather than identity) seemed to make him very happy. He placed the containers next to each other and made believe he was putting something inside one, then inside the other, saying, ‘Paul pours milk.’ He spoke very distinctly, as though emphasizing the grammatical construction. Then he turned round and carefully observed the central heating radiator. This radiator had two protruding pipes at each end: one large and almost flat, and the other long, L-shaped, and pointed, with a bolt having a rounded concavity at its tip. He picked up the container he had previously used to fill up the two oval dishes with, approached the large flat pipe, pretended to fill it up, and said, ‘Pshitt.’ He proceeded to do the same with the pointed, L-shaped pipe. Then, leaning his back firmly against the wall, he slowly brought the corner of his right eye up to this pointed pipe, all the while looking me straight in the eye. He seemed to be ‘thinking’. He went to pick up a small stuffed duck made of very soft material, with a soft felt beak, which had been very useful to him in the past when he had been working on recovering the ‘amputated’ contour of his mouth. He returned to the ‘pipe-beak’ of the radiator and placed the soft beak of the duck over the hard metallic ‘beak’ of the radiator as he brought the corner of his eye up to this doubly penetrating object. Then he positioned himself in front of the pipe and made the soft beak penetrate the concavity of the bolt at the tip of the hard beak. Tustin frequently illuminated the material of her autistic patients by means of quotations from the poets, who she felt intuitively grasped these states. A friend of mine, the poet Maurice Cesbron, has written verses from which I would like Downloaded by [New York University] at 03:54 14 August 2016 to quote in the context of this material on the bisexuality of the glance, and the alliance of hard and soft in the process of inscription in the psyche:

Reflection Under the rootless tree As upon the rose within its garden, Of a male glance whose feminine Soul applies its point to the secret Of moss nonetheless in love With wood that nothing – Deep axe, extreme sword – Can ever touch Except this thorn. 58 Geneviève Haag

To return to Paul I could then interpret, in the transference, that baby Paul needed not only to drink good milk, but also to have the good soft eyes of a mother entering his eyes, and to have himself a soft eye-beak with which to enter mother’s eyes. With this, Paul left the corner by the radiator and – holding the toy duck firmly in his hand – walked along the wall pressing against it with the duck as though leaving imprints. He slowed down in front of a sharp pencil mark he had made a long time before to represent penetration. (At the time he had recovered eye contact, he had frequently contemplated this mark with the same jubilation that accompanied his increasingly daring glances.) He proceeded with symbolic play in which he fed a little doll, which he then placed in a tiny cradle next to a teddy-bear. He lay on his back on the couch and glanced at me joyfully. Suddenly he jumped up on the couch, said, ‘the corner,’ and inserted himself in the angle where the two walls met, with his spine in the corner. He bounced on the couch, then became excited and went on to more Oedipal material involving a castration phantasy about cutting his fingertip. I shall leave until later the theoretical discussion of these clinical phenomena, which raise questions concerning cathexis of the body, the construction of spatial concepts, and levels of representation and symbolization. I shall now proceed with clinical examples of the second major stage in the construction of the body-ego.

Mother and baby in two halves of the body: the lateral object of primary identification In Paul’s material, the introjection of the containing qualities of the therapist’s eyes is followed by the integration of back/penetrating gaze/making a mark on the bottom-floor (represented by the walls against which he pressed the toy duck). At this stage, the container could be represented by an architectural form with angles, and he shows us clearly the correspondence between angled recesses or ridges in the walls, and the vertebral axis joining the two halves of the body. (In the first stages of recovering the containing function, he had represented it by a circular shape: a little round tray.) Downloaded by [New York University] at 03:54 14 August 2016 I became aware of the pathological importance of the vertical axial joint long before I realized its significance for development. The pathological phenomenon, especially evident with autistic children, is a vertical split of the body image. This was described by Tustin (1981) as a binary split of the body-ego in children whose encapsulation was intended to hold the two parts of the body together. I have provided a large number of examples of this from my own practice (Haag 1985). A little girl, Arielle, compared the two halves of the body to two parts of a small dolls’ house connected by a hinge (the well-known Fisher Price dolls’ house), and also to two identical boxes which she alternated between gluing together and pulling apart. She showed me that she had to lie down and Further reflections on the construction of the body-ego 59

stiffen her body in order to keep the two halves together. Another girl, Celine, would keep her hands and feet ‘glued’ to either side of a central line on a decora- tive tile, itself placed at the centre of a hallway, and she kept her eyes glued to her hands and feet. A third little patient, Auina, had a particular need to take hold of somebody’s hand in order to ‘do things’ with it. One day, she drew a picture of herself with her teacher as a double body, covered on the one side and with two confused arms on the other. I have an increasing conviction that this common maneuver of autistic children – to have someone do things for them – is related to a phantasy of one half of their body being confused with half a body of another person. Some autistic children walk as though they were hemiplegic (not using half of their body), although they manifest no spastic symptoms. In the analysis of adults, bodily experiences can include: differences in size between the two body-halves, in which the larger half holds the smaller; sensations of loss in one half of the body; or convulsions in half of the body without any medical significance. The way in which patients move their hands while lying on the couch is another related area. Dream material provides an abundance of illustrations. For instance, shortly before a break, a patient dreamt that he was jumping from one rock to another, with somebody behind him. Suddenly, he noticed that the person behind him had disappeared. He then saw, on his left, a country road. In the distance, he saw a ruined mill with a damaged mechanical waterwheel. One aspect of this dream suggests that the loss of the analyst from behind (as a background object) is linked – by the loneliness of the left part of the self – with a damaged object. The right side would seem to be lost together with the background. This loss may be condensed with and aggravated by the envious attacks on the combined internal object – mill-mother and waterwheel-father. Bearing in mind clinical experiences of this kind, I was struck during numerous observations of infants between the ages of four and eight months by the importance of the linking of right side with left, and of self-carriage and self-holding between the two hands and two feet. This contrasts with the disjunctions in the clinical examples. The linkage clearly reflects the quality of feeding, care, and attention provided for the baby. I have also often observed how the abrupt distancing of a person, particularly one who has been attending to the baby, Downloaded by [New York University] at 03:54 14 August 2016 provokes a movement in the right arm of the baby that looks as though it were responding to a magnetic force, and seems to connect itself to the body of the adult who is moving away. One five-month-old baby kept pulling his right arm back with his left hand, as though retrieving it. An eight-month-old baby used its left hand to clutch onto the middle finger of the hand of his outstretched right arm, as though the right arm had gone away in the direction of the mother’s body. In contrast, when a baby of three and a half months had been left for a little too long, he kept trying to find his mouth with his right hand. It looked as though this took extra effort, and the right hand kept failing and falling back. Similarly, the 60 Geneviève Haag

right hand failed in its attempts to find the left hand and hold onto it. Thesefailures persisted and worsened during a very uncomfortable half-hour, despite the baby’s desperate efforts. The moment Mother returned, the baby made a beautiful enveloping movement with its right hand, unerringly homing in to grasp its left one.

The appropriation of the lower limbs around the line of horizontal splitting: limb and head joins with the trunk I will conclude these clinical examples with a short section on the third stage of the process of constructing the body image.

The incorporation of the lower limbs At the age of about five months, babies begin to grasp their lower limbs, to pull at them, and to experience them as attached to the body: body unity is centered around the horizontal axis of the pelvis. Sometimes, the bringing together of two limbs can show a cross-over in terms of symmetry around horizontal and vertical axes – for instance, the right hand may grasp the left foot. Another indication of the later-date integration of the lower limbs is their ready use, in times of conflict, for the expulsion of painful feelings and the localization of bad objects. For example, a four- to five-month-old baby, getting used to being in a nursery, is given the bottle for the first time by a caregiver in the mother’s presence. He ‘expresses’ having accepted the bottle by an excellent initial adaptation with the upper part of his body. His lower limbs, however, instead of articu- lating in their usual way, show an expulsive movement of a partially ‘bad’ experience. Likewise, a seven-month-old baby showed how his whole body resonated with the feeding experience, his right hand moving rhythmically in correspondence with the arrival of the spoon, while his left palm turned outwards and forwards each time he swallowed. It was only through his legs that he showed that he did not like fish, as his mother said: his left leg kept attacking his right leg (Haag 1985). It took me a long time to realize and to understand the relatively belated appearance of the need to bend in the development of autistic children: to fold over in half, either when standing or when lying down, as though to confirm the Downloaded by [New York University] at 03:54 14 August 2016 presence of the hip joint. By the same token, we can understand better the prolonged manic states that can emerge during the treatment of children who were formerly autistic or psychotic. During these periods, the central phantasy is that of repossessing the other in a mutual incarceration of a tyrannical and tortur- ing nature – usually set in a dark underground location – which evokes a common bottom and may or may not be accompanied by anal masturbation (Meltzer 1966). This seems to be the last outpost of what one could call ‘body-phantasies’ on the way towards greater mentalization. Thus it seems that the appropriation of the lower limbs goes together with the development of erogenous anal and sexual zones. It is at this nodal point that we Further reflections on the construction of the body-ego 61

can discern a more mentalized ego, with the hypochondriacal constellation as part of the manic-depressive, psychosomatic, and visceral difficulties, which constitute one possible pathway. Another pathway is hysteria along with the horizontal split of the body image, a familiar association since Freud.

The small and large joints of the limbs These joints are also primitively cathected as links, especially the joints of the hands and fingers. In states of autoerotic illusion the hand is the first representation of the breast. Contemplation of the hand joints seems to be part of this autoeroticism. The wrist joint is a special object of contemplation and becomes a target for attack at times of unhappiness. The shoulder and the knee are especially linked to the roundness of the breast, while the elbow is linked to a phallic- aggressive element. In all cases of serious pathology, it is helpful to understand the joint as a link between one part of the limb, representing the self, and another part (usually the distal part) representing the object.

The junction of the head with the trunk: the neck joint In normal development, babies observed between ten and twelve months show a new awareness of ‘thinking’ as being located in the head. This location is manifested by their placing their little picture books over their heads. My present understanding is that, prior to this stage, the head in the body image is welded to the trunk, both as regards sensations in the back and with reference to the vertebral axis. We must remember that when a child of about two moves through space by walking, primitive bodily anxieties are concomitantly revived along with the unfolding process of individuation. At this time, many children show little maneuvers aimed at ‘getting into their own back’, such as drawing the head down between the shoulders, or using threads or cloth to place around their head, neck, or shoulders. Could such phenomena be linked with the fact that more mentalized anxieties, which by now no longer threaten the integrity of the body as a whole (the achievement of sphincter control and a sense of boundaries is on the way), are felt especially at the level of the neck? If so, this would be the cusp between psychotic Downloaded by [New York University] at 03:54 14 August 2016 and neurotic bodily anxieties.

Theoretical considerations

Concerning containing introjection The observations on the need for support to the back naturally relate to the definition of what Grotstein (1981b) first called the ‘background object of primary identification’, and now (Grotstein 1990) prefers to call the Background Presence – apparently a Kohutian ‘self object’ – which denotes a state of partial 62 Geneviève Haag

fusion (for example, symbiotic Siamese twins). He relates this concept to Sandler’s (1960) ‘background of safety’, to Winnicott’s (1951) ‘environmental mother’, and to Bion’s (1967) innate ‘preconceptions’. Grotstein proceeds to liken it to the dream screen, and, in his ‘dual track’ theory (1978), refers to it as a ‘guardian of the nascent feeling of object constancy’, prior to the establishment of object-representations, at which time it is transformed into a divine concept associated with the superego and with the ego ideal. My thanks to Joscelyne Delegay Siskou for having drawn my attention to the small joints. This became very useful in understanding the self-mutilation inflicted upon themselves by some psychotic children. Adhesive identification, as described by Bick (1968, 1986), is relevant to the nature of the identifications discussed in this paper. She considers this a defensive mode of being ‘stuck onto’ the object in two-dimensionality, skin to skin; or by any other sensorial modality that assumes the tactile aspect of a ‘suction tentacle’ (Symington 1995); as well as through imitation, such as echolalia. This defense is meant to protect against the ‘dead end’, where one can either fall endlessly or liquefy (postnatal anxieties). But Bick also discusses a normal developmental process, quoting Greenacre’s (1970) notion of the ontogenetic defenses of the organism, which appear early on and are later transformed into the mental defense mechanisms of the mature ego. Bick also refers to Gaddini’s (1969) discussion of the role of primitive imitation in the formation of identificatory processes. Bick states that she is attempting to outline the processes of the most primitive holding-together of the infant’s body-ego, as this is formed conjointly by the mother-and-the-infant-in- the-family. Thus, she also emphasizes the environment’s group character as an external containing object, which is of great interest with regard to what I call the normal adhesive component of group envelopes. In her teaching, Bick (1986) advanced the hypothesis of an ‘adhesive position’ similar to the notion of the paranoid-schizoid and depressive positions. I believe that we need to differentiate between normal and pathological ‘adhesive identity’, since this mechanism is also operative as a defense in pathological autistic states. In these, it is used primarily as a defense against any feeling of bodily separateness, functioning as pure auto-sensuality against any object-

Downloaded by [New York University] at 03:54 14 August 2016 related emotional link. At the same time, it seems to me that there is a primitive kind of emotionality operating in this two-dimensional fusion. I would relate it to Meltzer’s (1988) considerations on the ‘aesthetic object’ as well as to emotional modalities of pre-natal life. Might the feeling of ecstasy be two-dimensional – a kind of ‘stuck onto’ or ‘fused with’ feeling – where the sense of a separate identity is more or less abolished? Maldiney (1982: personal communication) suggests that we are here letting ourselves go more or less fully into ‘autistic’ contemplation – that there is no art without autism. Milner (1955) also addresses this problem, stating that: ‘The basic identifications which make it possible to find new objects,to find the Further reflections on the construction of the body-ego 63

familiar in the unfamiliar [my italics], require an ability to tolerate a temporary loss of a sense of self, a temporary giving up of a discriminating ego.’ On the same page, she also suggests that it may require the state of mind described by Berenson (1950) as ‘the aesthetic moment’. The problem of differentiating between normal and pathological adhesiveness may have to do with the nature of the sticking (normal sliding as against pathological tentacle action) and also with its duration. It is as though normal ‘sticking-to’ needed to be free to bounce back towards the self, like the clapping of hands; in any case, I imagine it as a kind of surface contact similar to a rhythmical sliding (like skiing or skating?). In contrast, pathological adhesiveness involves remaining rigidly stuck to an inanimate, emotionally non-vibrating object. Is the dread of being sucked in – as into a whirlpool or quicksand – a corollary of this stuckness, which, like Bick’s suction tentacle, defends against anxieties of liquefaction and of falling forever? In the pathological case, there is no experience of a supple external object into which the baby can slide thanks to its ‘capacity for reverie’ (Bion 1962) or ‘primary maternal preoccupation’ (Winnicott 1960). If all goes well, the baby can feel those rhythmic labyrinthine and auditory experiences in prenatal memory traces as well as in the holding postnatal oral experience of cradling and feeding that impart a sense of the initial emotional adhesiveness being returned to him in a to-and-fro movement. This is at first experienced in terms of bodily substances (Tustin). Later and gradually, a tiny spatial leap begins to take place, particularly in the realm of eye contact. This is underpinned by a budding confidence that there will be a response through which something is returned to the baby – sufficiently similar but with a crucial small difference, encompassing both accommodation to the baby and transformation of what he brings. Grotstein (1981b) emphasizes an important quality of the background object: the phantasy of a new-found container whose elasticity is tested by the process of containment (as related to stress). In his theory of the ‘dual track’, he suggests that the baby functions at the same time with a feeling of separateness and with a beneficial process of adhesive identification. I subscribe to this point of view. We can observe very concrete illustrations of the simultaneous operation of projective and adhesive identification in the construction of the body image. For

Downloaded by [New York University] at 03:54 14 August 2016 instance, babies between three and nine months may be involved in an intense projective and introjective communication with the mother in what we could call literally a ‘tête-à-tête’. Simultaneously, however, their bodies, at the level of the trunk – thorax and arms – may exhibit the kind of ‘magnetized’ movements described earlier in a baby’s arm when the mother got up. Further down from the head, the dominant half of the baby’s body is still in a state of adhesive identity with the mother’s body: it is as though the baby could not foresee the mother’s getting up, and so ‘take back’ the half of the body held in common by means of a maneuver involving autoerotic illusion. Different identificatory mechanisms can thus operate simultaneously for different levels of the body. 64 Geneviève Haag

Discussion of the mechanisms of pathological autism: a dialogue with Frances Tustin I would like to include here a brief discussion on the operation of pathological autism, in which I aim to establish a dialogue between Tustin and other authors whose contribution I value. This discussion was included in the conference Homage to Frances Tustin that took place in France in 1992. The French version was published in the Revue Française de Psychanalyse, while the English trans- lation by Theodore Mitrani was included in the Memorial Tribute to Frances Tustin edited by him and Judith Mitrani (Haag 1997). This discussion centers on the question: what brings about the sense of amputation in autistic children’s experience of bodily separateness? Tustin takes up the problem of the sensation-ego, the loss within the sensation-ego, and the analysis of the earliest forms of projection.

Loss in the sensation-ego Discussing her patient John, Tustin writes:

He felt, for instance, that his mouth lost an exciting cluster of sensations for which, ever afterwards, he was destined to grieve. A sensuous impression which he had taken for granted as being ‘there’ was suddenly ‘not there’. (1981/1992: 88)

It seems to me that this is an example of a form of ‘negative hallucination’, as described in the work of André Green (1982). Tustin states that, for the autistic child, this sensation of lack becomes ‘catastrophic’ (the abyss) and is immediately plugged up by the ‘positive hallucination’ of hardness that autistic children have recourse to. The baby needs to come up against the hard ‘bottom-floor’ in the mother’s head to feel that its emotional communication, mediated by visual interpenetration, is received, transformed, and returned. When the communication is lost behind the mother’s eyes, and the sensation of the mouth with it, the baby experiences the threat of annihilation on the brink of the abyss, and turns to the positive hallucination of excessive, pathological hardness – of muscular contrac- Downloaded by [New York University] at 03:54 14 August 2016 tion, for instance. Such metapsychological considerations are relevant to states of depersonalization in adults, or to familiar psychiatric syndromes accompanied by the negative hallucination of parts of the body. Such a hallucination may also involve the projection of predatory forms of atavistic instinctual elements, poorly transformed into misdirected drive dynamics. Although Tustin does not elaborate, she makes it clear that it is her understanding that both the negative and the positive hallucination – registering as sensations of hardness and discomfort – are also a part of normal functioning necessary in facilitating the birth of awareness of the self and objects. Tustin (1981) suggests that ‘when the child becomes able to tolerate the fact that hard, Further reflections on the construction of the body-ego 65

uncomfortable “not-me” experiences are a part of “me-ness” and of the “me”, the toughness and resilience necessary to tolerate the “not-me” develop.’ Tustin then presents her considerations regarding the precursor of projection: the flowing-over-at-oneness associated with ‘adhesive identification’ (Bick 1968) is earlier than projection and identification, which imply some degree of a sense of bodily separateness between mother and infant. She credits Imre Hermann (1929), who had already mentioned this ‘overflowing’ as a precursor mechanism to projection. I find that this notion is close to Green’s (1971) thoughts on projection, especially his idea of ‘excorporation’ in the constitution of the dynamics of drives. If this excorporation – of that part of the body in which tension is felt (Green 1971) – is not received by an external object, the ‘projective field’ fails to materialize. Following on from this, I raise the following question: is it not at this juncture that, instead of the establishment of a brief experience of ‘not there’ which might stimulate a thought (at a pre-perceptive stage) about an object which could return, there can be an experience of amputation or of ‘gone forever’ that the child needs to plug up immediately and continuously through the use of the hard ‘positive hallucination’ discussed by Tustin? Through our understanding of this, we may be better able to understand the way in which hallucination – sustained by means of autistic objects – replaces the love object, since in normal development the object and the ego are progressively born within the dynamics of normal projective identification (Bion 1957; Rosenfeld 1965). Normal projective identification requires an object that can receive the excesses both of positive libidinal excitation and of aggression. The return of what was projected – along with the essential transformation of it – seems then to contribute towards the construction of a primary boundary. I have reported in a number of papers on the way that children within the transference relationship express the feeling of the return of the overflow or excorporation, which creates the perception of an undulating shape, perhaps the first form of a containing boundary. Laurent’s material is an example of this. Certainly, Green’s notion of excorporation could also be linked to the flow of primitive emotions in terms of bodily softness – as addressed by Tustin in later papers – which would take place in flowing-over-at-oneness, implying that in the beginning there is merely a surface experience. The term ‘projection’ is more Downloaded by [New York University] at 03:54 14 August 2016 appropriately used (as both Green and Tustin observe) as applying to a state of three-dimensionality, which implies the acquisition of an initial boundary, a ‘psychic skin’ (Bick 1968) or ‘skin ego’ (Anzieu 1985), along with a minimum of space between the bodies, or rather the primary body images. I now return to the question of different kinds of identification. We have refined our concepts in order to differentiate normal projective identification (Bion 1962a), using a receptive container, from pathological projective identification, also called intrusive identification (Meltzer 1982), as described by Klein (1946) with regard to psychotic states. By the same token, I believe that we need to distinguish between pathological adhesive identity and 66 Geneviève Haag

normal adhesive identity. The normal version would be the kind of ‘sticking onto’ that imprints, that assimilates itself to, including the component of similarity in both affective and cognitive phenomena as well as in normal group rituals. It seems that at present, this adhesive identity is usually called ‘massive projective identification’. What would be the difference between the adhesive and the projective forms of identification? (Indeed, the projective contains the adhesive within a three- dimensional experience, within an existing sense of a primary enveloping and encasing skin (Green 1974).) This accounts for a phantasy clearly communicated by children as well as in some thoughts and dreams of adults, of getting ‘stuck to’, or ‘clinging onto’, with a tiny spatial leap, inside someone’s head, while the other person sticks ‘something’ inside one’s own head almost as a mirror image. Additionally, it may be a matter of the absorbent, imprinting nature which can flow from the kinaesthetics of oral experience imprinted in its tactile origin upon the backdrop of thoughts and the dream screen (Anzieu 1985; Freud 1923). Autistic children show us that only the revival of gaze/attention allows them to make this spatial leap within a common skin, which envelops two vesicles on their way towards differentiation. Anzieu’s (1985) excellent contributions are highly relevant and important with regard to the qualities of this skin-function. I agree with Botella’s (Botella et al. 1977; Botella and Botella 1984) analysis of the role of normal erotism in the duplication of links: namely, that the non- violent appropriation of shared bodily and psychic zones may be a pivotal factor in the movement between adhesive states and three-dimensional symbiotic states. Surely the first experiences of sucking contribute to the emergence of ‘the head’ in the body image. Besides the issue of splitting, as I have discussed elsewhere (Haag 1988), there remains the issue of the skin held in common between two people, or of a given aspect of either the body or the psyche held in common, also addressed by McDougall (1989). We may say that, prior to the establishment of the primary skin, the bodily anxieties are those of falling endlessly and liquefying, according to Tustin (1972a, 1985b) and D. Rosenfeld (1984). According to these authors, and according to my own experience, these anxieties seem more primitive than the anxieties associated with minute splitting, the latter being an aspect of oral Downloaded by [New York University] at 03:54 14 August 2016 sadism in the dynamics of projective identification associated with a three- dimensional body image. Tustin (1986a) points out that between the two sets of anxieties there appears the phantasy of a sphincterless tube-ego, which no doubt underlies the vampire anxieties linked to circulatory tubes on a most primitive level. David Rosenfeld (1984) observed that the appearance of solidification of contents in the digestive process suggests an improvement in the containing function. Nevertheless, the phantasy of a sphincterless tube-ego within an erect body remains an important element at the core of anorexic adolescents (Kestemberg et al. 1972; Tustin 1986a). Further reflections on the construction of the body-ego 67

Concerning the two halves of the body After encountering Grotstein’s work on the ‘background presence’, I coined the term ‘lateral object of primary identification’ in the effort to theorize my description of ‘the-mother-and-baby-in-two-halves-of-the-body’ (Haag 1985). The identification of the two sides of the body with the two parents is better known, albeit on another symbolic level, and seems to be detected in observations from the second year of life. The previous identification which I am discussing here seems to belong to the same level as part-objects and certain functions of objects, especially that of ‘holding’. At the same time, there does already seem to be a certain degree of bisexuality of some primary parental qualities. For example, in the case of the mother and baby in the two halves of the body, the paternal quality seems to be indicated in the link, the pivot, the hinge, and the median axis. This conceptualization is in keeping with that of the background presence. I suggest that the background presence extends partly into the vertebral axis (father), and partly into the lateral presence of primary identification (mother). Would not such a configuration evoke the image of our guardian angel? Phenomena such as playing with the hands are undoubtedly an important link in the autoerotic work of disengaging the two half-bodies which are stuck to each other. The work is as indispensable for the owning of one’s body as is thumb- sucking, which, beginning at an earlier level, plays a vital part in the establishment of the feeling of a combined envelope/skeleton which sustains the first mentalized reveries. The detailed analysis of hand joints/articulations reveals exciting details concerning the balance between envelopes and penetration, emotional nuances of possession, and so forth. It seems certain that these phenomena contribute to trig- gering the process by means of which the child can take possession of the upper limbs and of the trunk. It truly seems that the body image is progressively acquired from top to bottom.

Conclusions Observations of the kind I have discussed lead us on to many interesting speculations. Undulating shapes, circles, spheres, angles, edges, such as we have encoun- Downloaded by [New York University] at 03:54 14 August 2016 tered in relation to small children, have a bearing on the ability to perceive architectural forms, as well as on their meaning and impact. This is an area I am working on at present. In the realm of psychoanalytic theory, these considerations concerning bodily identifications raise the whole question of levels of representation. Might not these forms we have encountered be an aspect of unconscious phantasy, as considered by Susan Isaacs (1948)? She writes, ‘Before long, the child’s phantasies are able to draw upon plastic images; these plastic images and representations of phantasy are progressively elaborated along with articulated perceptions of the external world.’ In a note, she cites Dr Clifford Scott: ‘We need to know 68 Geneviève Haag

more about what “the body” means in unconscious phantasy.’ Perhaps we are part of the exploration Dr Scott was suggesting. In this chapter, I have put forward some reflections on the construction of the body-ego in the footsteps of Frances Tustin. I hope that our ongoing reflection will lead to a further appreciation of this primal dimension.

Note 1. This paper is a transcript of the First Frances Tustin Memorial Lecture, held at the Tavistock Clinic on 5 September 1997. Originally published as ‘In the footsteps of Frances Tustin: further reflections on the construction of the body-ego’,Infant Observation: International Journal of Infant Observation and Its Applications. Downloaded by [New York University] at 03:54 14 August 2016 Chapter 5 Finding the wavelength Tools in communication with autistic children1

Anne Alvarez

Listening is a complex art. A few years ago, there was a series of letters in The Times on the subject of blackbirds and their song. Here is one from 14 June 2000:

Sir – Blackbirds are joyful in May and sing in A major. In July, they are content and sing in F major. I’ve waited 68 years to say this, Beethoven’s Seventh and Sixth Symphonies supporting my theory. Sincerely, D. F. Clarke.

The writer is clearly a good listener and seems to like listening. Here is a rather different attitude toward listening, this one by Fernando Pessoa (1981).

Cease your song! Cease, for along with It I have heard Another voice Coming (it seemed) in Interstices Of the charm, softly strong Brought by your song as Far as us

Downloaded by [New York University] at 03:54 14 August 2016 … No more song! Must Now have silence, To sleep clear Some remembrance Of the voice heard, Not understood, Which was lost For me to hear. 70 Anne Alvarez

Note the insistence that what one needs in order to listen is silence, not song. Children with autism are notoriously poor listeners: indeed, they are often thought to be deaf. The established triad of symptoms includes, as well as impairments in social relatedness and the use of the imagination, impairments in communication and language development. It is important to identify symptoms, yet a nosology which relies too exclusively on a one-person psychology – that is which sticks to describing attributes of the child’s self – may tell only a part of the story. I think a fuller descriptive psychology of autism is provided by a two- (and eventually three-) person psychology. Such an approach involves a study of intra-personal relations: in a model of the mind which involves a two-person psychology, the mind contains not just a self with particular qualities and orientations and possible deficits; it also contains a relation to, and relationship with, what are called ‘internal objects’ (Klein 1935) or ‘representational models’ (Bowlby 1969, 1973), and these too may contain deficits. A more personal, intra-personal view of autism carries the implication that the self is in an emotional, dynamic relationship with its internal representations, figures, objects – no matter how skewed, deficient, or odd this relationship may be. (There is no aetiological implication here: it is the child’s inner world of figures and representations that are at issue. Many psychoanalysts use the term ‘internal object’ rather than ‘representation’ as the latter may sometimes be taken to imply an exact copy of external figures, whereas the former carries no such implication. Internal objects are thought to be amalgams of both inner and outer factors.) If the child treats us as a piece of furniture, he may be seeing us as something like a piece of furniture, and he may also feel as though we are like a piece of furniture. If he does not listen to us, it may be in part because he does not have the habit of listening, but it may also be because he finds our talk uninteresting, or intrusive, with too few of Pessoa’s silences. How, then, are we to cease our song and still be heard? Also, if he does not talk to us, it may be in part because he does not think we are worth the effort of speaking to, or because he feels our listening capacities are limited. Or else he may feel we want to pull his words out of him so that, in some sort of terrible way, they will become ours and no longer his. His ‘theory of mind’ (Leslie 1987) may assert that minds are basically unmindful: this can do major damage to processes of introjection, learning and Downloaded by [New York University] at 03:54 14 August 2016 internalisation. Yet symptomatology and pathology are not everything: each person with autism can usually be found to have an intact, non-autistic part of the personality interwoven with their autism. Bion described the importance, in psychoanalytic work with psychotic patients, of making contact with the ‘non-psychotic part of the personality’ (1957). There is also now a growing body of research on ‘spared function’ in autism (Hobson and Lee 1999). For all its apparent stasis, the autistic condition is less static and more mutable than it sometimes appears. While a micro-second’s interested glance by a child at a person, say, or a new toy, may be followed by an instantaneous return to old rituals, the quality of the Finding the wavelength 71

child’s glance may nevertheless offer a clue, a faint signal that can be amplified and built upon tactfully. It is important to assess what the developmental level is at which this apparently more normal part of the self may be operating. The child’s chronological age may be five or ten years, but, because of habitual life-long interference from the autism, the healthy, related, object-seeking part may be functioning at ten months or even three weeks of age. Traces of early preconceptions (Bion 1962a) – or of not so much a ‘theory of mind’ (Leslie 1987) or of person (Hobson 1993) but a proto-theory of mind or a proto-sense of person – may still be detectable. It is on this foundation that a treatment – precisely calibrated to the level of emotional communication of which the child is capable – may be built.

Normal infant development, vision and proto-language William, 13 months old, heard his father getting up at five a.m. outside his door. William called ‘Ey!’ The father said it sounded like, ‘Hey! What are you doing! Where the heck are you going?!!!’ Dad opened the baby’s bedroom door, and was greeted with another demanding ‘Ey!!!’ Dad whispered, in order not to wake the mother, ‘I’m going to work, William, you go back to sleep now.’ William said, ‘Awhhhh’, and went back to sleep. From the moment of birth, as the psychoanalyst Klein maintained, and developmental psychology research has subsequently demonstrated, normal babies are now known to be extremely precocious socially. They have all the basic equipment they require to begin to engage in face-to-face interpersonal communication – initially of a non-verbal kind. They prefer to look at face-like patterns, to listen to the sound of the human voice, and they have a remarkable capacity for finely tuned interpersonal exchanges (Stern 1985: 40; Trevarthen and Aitken 2001). Clearly, emotional communication involves a whole orchestra of ‘instruments’ in which eye gaze (Fogel 1977; Koulomzin et al. 2002), emotional engagement (Demos 1986), level of attention and interest, expressive bodily gestures (Hobson 1993), and vocalisations (Trevarthen and Aitken 2001) all play their part. Most of these instruments are used both expressively and then communicatively, or, to put Downloaded by [New York University] at 03:54 14 August 2016 it in psychoanalytic terms, via different types of projective identification. They are also used, however, for purposes of introjection and internalisation. Vision, for example: at birth, the infant has a set of visual structures highly sensitive to those aspects of stimulation that emanate from other people’s faces (Papousek and Papousek, 1978). Schore (1997: 10) points out that the caregiver’s emotionally expressive face is by far the most potent visual stimulus in the infant’s environment, and the child’s intense interest in her face, especially in her eyes, her brightening and dulling gaze (Robson 1967), leads him to track it in space and to engage in periods of intense mutual gaze. Eyes, after all, have what Robson calls, immense ‘stimulus richness’ to the newborn: their shininess, 72 Anne Alvarez

mobility, and the micro-second by micro-second changes in the size of the pupil attract attention, at first only fleeting but nevertheless frequent (Fogel 1977). After the second month, fixation on the mother’s eyes increases (Maurer and Salapatek 1976). At 17 weeks the eyes are a more attracting feature of the mother’s face than her mouth (Uzgiris and Hunt 1975).

Language and triadic skills involving visual regard Towards the end of the first year of life, infants begin to extend the use of an earlier skill: the capacity for gaze monitoring. Scaife and Bruner (1975) have shown that even very young infants will turn their heads to follow the mother’s line of regard. In the last quarter of the first year, following the trajectory of another’s gaze and gazing at the object of the gaze are intensified, as the baby is motivated to keep track of his mother and her comings and goings. This is followed by the emergence of the more proactive activity of proto-declarative pointing between the ninth and fourteenth month (Scaife and Bruner 1975). Bruner (1983) was one of the first to point out that language arose in the context of interactions between infant and caregiver. It was here that the infant learned to understand that there was more than one perspective, but that differing perspectives could be linked (Urwin 1998). Burhouse (2001) has offered suggestions as to the emotional preconditions which might explain why gaze monitoring seems to precede proto-declarative pointing. She points out that the baby has learned to value mother’s return of gaze during the early months of face-to-face dyadic mutual gazing, and this interest in and valuing of her attention leads the baby to follow her gaze when it goes to someone such as an older sister. Eventually, the baby finds active ways of getting this attention back, through communicative pointing and expressive sounds. These are emotionally laden events, and the grammar of emotional events structures language. There are huge differences in communicative intention between a ‘Hey there!!!’, a ‘C’mon give us a smile …’, an ‘Oh look at the lovely bright sun!’, a teasing ‘I’m coming to catch youuuuuu!’, a ‘You’ve been a very naughty boy!’, a ‘Oh you really like that banana puree, don’t you, oh yes yum yum’ and an imperative ‘Don’t touch that socket – it is VERY dangerous!’ Language, as Bruner (1983) taught, emerges Downloaded by [New York University] at 03:54 14 August 2016 always in contexts and, as developmentalists have shown, is accompanied by emotion (Demos 1986). Burhouse describes a moment when the baby seems to be thinking, ‘she (mine) is talking to and looking at her, not to me.’ Psychoanalytic theorists and developmentalists alike have suggested that early two-person relationships lay the foundation for the later three-person social capacities (Klein 1945; Winnicott 1958b; Trevarthen and Hubley 1978). Recently Striano and Rochat (1999) have demonstrated empirically that the link between triadic social competence and earlier dyadic competence in infancy is indeed a developmental one. You don’t follow the trajectory of someone’s gaze unless you find his or her gaze worth having in the first place. Finding the wavelength 73

Therapeutic implications of impairments in communication: getting on the right developmental wavelength The question of the psychoanalytic treatment of children with autism has been surrounded by controversy. Some psychoanalysts and psychotherapists have themselves described the need for changes in technique with these children (Meltzer 1975; Tustin 1981; Alvarez and Reid 1999). The impairments in symbolic capacity, play and language make an understanding of more ordinary explanatory interpretations very difficult for them. Where the autistic symptomatology is especially severe, and where not only the child’s sense of the existence of other people but also his sense of self too is weak, the concepts of transference and counter-transference may seem too advanced: transference may seem to be non-existent and a counter-transference of frustration or despair in the therapist can lead to indifference. Yet close observation may begin to reveal faint or disordered signs of relatedness which can then be amplified. The view of the Autism Workshop at the Tavistock Clinic is that, regardless of aetiology, a disorder of the capacity for social interaction may benefit from a treatment which functions via the process of social interaction itself, provided this takes account both of the nature and severity of the psychopathology and the particular developmental level at which the child is functioning. The therapeutic approach is three-pronged: it addresses the child’s personality, the autistic symptomatology (disorder and sometimes deviance) and the intact or spared ‘non-autistic’ part of the child, however developmentally delayed this may be (Alvarez and Reid 1999). The psychotherapy is thus psychoanalytically, psycho- pathologically and developmentally informed. The psychoanalytic perspective offers the close observation of the transference and counter-transference. This can alert the therapist to personality features in the child that accompany and may act to exacerbate or reduce his autism. (Some children with autism develop quite deviant personalities that are in no way an essential feature of the autism itself.) The psychoanalytic theory of the need and capacity of every ordinary child first to relate intensely to and gradually to identify with both of his parents contributes greatly to the understanding of normal child development. So also does the theory of the Oedipus complex, the under-

Downloaded by [New York University] at 03:54 14 August 2016 standing of the ordinary child’s disturbance at but also enormous interest in and stimulation by those aspects of the parental couple’s relationship that exist independently of him (Houzel and Rhode 2001). The psychopathological perspective helps the therapist to understand the power and pull of autistic repetitive behaviours and the ways in which (as psychoanalysts, too, have suggested), addictive and concrete non-symbolic behaviours differ profoundly from simple neurotic mechanisms and defences (Kanner 1943; Joseph 1982; Tustin 1981). Clinical intuition can be both confirmed and supplemented by the study of very young infants both by the methods of naturalistic observation (Miller et al. 1989) 74 Anne Alvarez

and of developmental research. Therapists try to identify and facilitate the precursors of social relatedness: the technique draws on findings into the ways in which mothers communicate with their babies, and into how this facilitates the infant’s capacity for communication and relatedness. The developmental research empha- sises a number of factors: the normal baby’s need for his level of stimulation and arousal to be carefully modulated (Dawson and Lewy 1989; Brazelton et al. 1974) and his attention channelled; the power of ‘motherese’ (softer, higher inflections with particular adagio rhythms during pre-speech/pre-music dialogues) (Trevarthen and Aitken 2001) and particular grammars (coaxing rather than imperatives) (Murray 1992); differing proximity of faces at different ages for eliciting eye contact (Papousek and Papousek 1975); and, depending on developmental level, the child’s readiness for primary intersubjectivity (face-to-face communication and play in a dyadic situation) versus secondary intersubjectivity (shared play with objects, where the baby glances at the caregiver seeking moments of ‘joint attention’ to a toy, for example – a triadic situation) (Trevarthen 1978). Yet many severely autistic children have never played or developed a capacity for joint attention. They may have no language at all; worse, they may never have babbled playfully. It may be a real achievement in the therapy when the non- speaking child begins to play with sounds, to make sounds that are more contoured than before. The technical issues for the psychotherapist are difficult: how can we reach a child with little or no language? How should we talk to such a child? I now want to describe work with a child where the use of both ‘motherese’ and something that might be called ‘fatherese’ combined to facilitate communication between us and to help his communicative capacities to grow. In both situations I often found that I had to contain and dramatise feelings that were either unfamiliar or unmanageable for Joseph. Yet he showed growing interest in my reactions.

Joseph Joseph was referred to me at the age of eight by his music therapist. He had been born two weeks overdue and had been induced. His older brothers were normal. Downloaded by [New York University] at 03:54 14 August 2016 Joseph was a placid baby, happy to be held by anybody, and he made eye contact until about the age of three. The parents only suspected something might be wrong when they tried to toilet train him at the age of two and he seemed not to understand. When they started to try to put pressure on him to communicate, he ‘closed down’ and eye contact reduced. He was always content, but he cut himself off and would not play with other children. He had always been tactile, cuddly and loved being sung to. He could sing numerous songs, but his spoken language was very limited. Joseph’s mother wrote that his early pretend play was good: from the age of two years he held two dolls facing each other and made them have ‘conversations’ with each other and dance together. Joseph did this in his sessions Finding the wavelength 75

with me, but for much of the time the quality was very closed and shut off and I think by now it was no longer real pretend play. It was too real for him: he seemed to believe he really was those people talking and playing together. Most of the language I heard in the early sessions was of this private type – conversations between various video characters, lively, interested, yet very repetitive and, for much of the time, impossible to understand. Occasionally a question could be heard or an exclamation. But to his parents and me, the only real word I heard directed to them or me was when we asked him if he would like to use the toilet, and he responded with an excessively light, quite disembodied ‘No.’ It was so light and impersonal, unaimed and unlocatable that you could easily imagine you hadn’t heard it. I saw Joseph together with his parents for three consultations. He occasionally responded to his mother’s songs, in the sense of joining in on the last word, but much of his positive connection with her was through cuddling. He was a big eight-year-old, and I did begin to note how easy it was to see him as younger than his age and to want to be protective of him: he was an attractive boy, with a sweet, rather unformed face and a very loose-limbed body, which in the room was much of the time horizontally laid out on the couch, half in his mother’s lap. He did examine the toys a bit, but avoided most suggestions or directives from her or me regarding any play activity. When walking, he tended to drag his arms and legs, especially his feet, after him as though they did not belong to him. I was cheered by more signs of alertness and life in a teasing game he began to play, in which he said, suddenly, ‘Night-night’ and then liked it when I did an exaggerated star- tle and expressed my disappointment that he was disappearing under the blanket again. He made a little fleeting eye contact after these moments. It was clear that Joseph was a very loved child, but there was also a sense in which he had never really wakened up to the world. He seemed to need to discover his bones and muscles, his verticality (his pleasure in standing and stretching up into the world, to jump and his capacity to move forward and explore it). There was far too much passivity in his life, and yet, as he so easily collapsed into a sort of panicky temper-tantrum when challenged or stretched, it was easy for everyone to suppose that his autism had made him far too delicate for ordinary life and ordinary demands. On the other hand, it was clear that both his parents and the school were able to be firm about certain things, as Joseph was Downloaded by [New York University] at 03:54 14 August 2016 in many respects a reasonable and easy-going child. After two months or so of psychotherapy I got the impression that the talk between the video characters, or between the toy animals, was not always as totally absorbing to Joseph as it seemed, that in fact he was often quite aware of my attention on him as he carried out these repetitive activities. I also began to think he was enjoying my feelings of exclusion, so I began to dramatise my counter-transference: ‘Oh, Joseph won’t talk to me, it’s not fair, nobody will talk to me, and they are having such a good time over there talking to each other.’ I also added sometimes, ‘Oh please talk to me, Joseph, not to them!!’ This was all quite emotional – coaxing/pleading/protesting. 76 Anne Alvarez

I was beginning to suspect that he thought of talking as something other people did together, with a third always excluded, but had no idea of the real pleasures of face-to-face talking in a twosome. I felt I needed to give the third a voice, and yet attract him back to real relationships. One day, after my coaxing, he looked straight at me, put his head up and back, starting to shake it just like a toddler, saying ‘No! Nononononono!’ and really relishing his power to tease and thwart me. But this had at least a bit of give and take: he was, after all, looking at me, and it was a genuine ‘no’ with some real oomph in it. Like his ‘Night-Night’ it was full of mischief and really made me laugh. Not all of my counter-transferences were so obliging, however. I sometimes found myself feeling very annoyed by his complacent assumption that only he and his shadow were interesting, or that he was not really bored silly by his unending conversations, or that he knew what was behind a particular wall in the room. Eventually I felt our relationship was strong enough for me to begin to challenge these assumptions. I began saying things like ‘Oh no, you DO NOT know what is in there behind that wall. You’d love to know, but you don’t!’ I said it strongly, but I kept it lively and fun and rhythmic, so it accompanied or responded to his sing-song-y style. Except that his was high and expressive, whereas I was bringing him down with my voice to a more earthbound but, I hoped, more interesting place. It was flatter and lower than his, but still quite humorous. I also persisted with the idea that his talk was NOT real, and that I knew he was dying to talk in a real way! The people in his pretend conversations seemed always to be having fun, or at least a dramatic and interesting time. But in order to become like someone, you also have to become aware that you cannot be that person. However, you also have to feel that other people give you permission to be like them. Therefore, on occasions when he came in very wild and excited, I echoed the excited/aggressive element in his utterances. If there were sudden growls and stamping of his feet, I copied and amplified both, which delighted him. I felt he needed to discover his musculature as well as his own boy’s voice. I also encouraged the toy animals to take longer journeys. They were often sitting around kissing each other most tenderly, but they never went for even a simple walk! I’m certain that even Anthony and Cleopatra went out for a breath of fresh air sometimes! I had frequently accompanied the animals’ large rather assertive steps Downloaded by [New York University] at 03:54 14 August 2016 (they always remained in the same place, or moved in the tiniest of circles) with even more assertive stamps of my own feet, but eventually I began to get a bit tougher over their unadventurousness. I began to insist that they were not scared, they DID WANT TO GO FURTHER, that HE was holding them back. He began to climb them up the back of the sofa and, unlike the days when all I could see was their backs, he placed them to face me from the top. As the first year progressed, Joseph took more and more pleasure in discovering his deeper voice and a more powerful and muscular self. His parents reported that he was making more eye contact and had begun occasionally to use spontaneous speech at home. Not long after the end of the second year, he began to Finding the wavelength 77

engage in what I think was real pretend play. He lay on the couch, shouted ‘Yee-ikes, ’elp, save me!!!’ as he ‘fell’ onto the rug. Although this scene may have come from one of his videos, it was not carried out in isolation as in the doll conversations where he usually kept his back to me: here he fell off the couch right in front of me, looking at me often, and if I was too slow to call out, ‘Help, this poor boy is falling off the cliff, we’ve got to rescue him, hurry, hurry!!!’, he pulled my arm to get it to reach out to his. The sequence was repeated, but somehow was never boring, perhaps because of Joseph’s delight in the high drama. Certainly, my involvement in the game was quite intense too: lack of a capacity for pretend play and for joint attention is one of the early markers for autism, and it is moving and cheering when they begin, however immature they may be in relation to the chronological age of the child. The game seemed heavy with meaning: sometimes I told him that I agreed – he did indeed need rescuing from his self-imposed autistic isolation and to be brought up and out onto firmer ground where there were other real people.

Discussion The technical issues in talking to a child like Joseph are difficult. Needless to say, I have only cited parts of sessions where I think I managed to find a way of being heard and encouraging proto-speech between us. Working with these children is never easy and the power of their autism is awesome. However, it is interesting to think about how to talk to these children and why particular methods may be more useful than others. I think there were many different motives for Joseph’s repetitive talk. Sometimes he did seem totally absorbed in it but, as I said, I began to think that at times he was definitely monitoring my response to it. And he did become less autistic when I gave urgent voice to this excluded third. This suggests that there was a communicative element in the projection at such moments. Or should we call it a proto-communication? He may not have expected a response, but he recognised it and seemed delighted by it when he got it. At other moments, when I felt his ‘talking’ was more arrogantly self-indulgent, I challenged him. I think he needed both the more receptive coaxing ‘motherese’ from me, and also the more challenging ‘fatherese’. There seem to have been two aspects to the father’s voice in the room: first, a father who declines to indulge omnipotence, Downloaded by [New York University] at 03:54 14 August 2016 who makes demands on his child to learn and grow, and who makes it clear that the child is not the same as the grownups; second, the father who invites and permits identification (with the strong voice and the potency of the stamping). Both only worked when I got the tone right. I suspect that when I challenged him too strictly, it may not have permitted the kind of identification he needed with a strong father. What seemed to work better was a firm, slightly bored tone or a more humorous teasing. Some identification processes seemed to be beginning with his deeper growls, strong stamping and standing tall. Some identification with father certainly aids the tolerance of Oedipal rivalries, and enables omnipotent methods to be replaced by a more realistic sense of agency and potency. 78 Anne Alvarez

I have described elsewhere the need to approach the child with autism on the right band of intensity (Alvarez 1999) but it is interesting that Barrows (2002) has been even more specific in introducing aggressive play to a child with autism and Salo (2007) has also found the introduction of aggressive play to a cut-off infant very helpful. To return to the more receptive or maternal function: Bion talked about ‘alpha function’, a function of the mind that makes thoughts thinkable and lends meaning to experience. He suggested that the mother’s reverie provided the necessary emotional containment of experience that enables babies to think. He described this in terms of the mother’s containment of the baby’s distress which had been projected into her and then transformed there by her capacity to think about and process feelings (Bion 1962a). But as developmentalists like Stern (1985) and Trevarthen and Aitken (2001) remind us, these processes do not concern only moments of distress. Babies need to impress, to delight, to bring a light to the parents’ eyes, to surprise and astonish them, to make them laugh. And they also need to be given room and space and time in which to do all this. We all may need to learn to keep our distance, know our place, wait our turn and bide our time – and, especially important, respect the child’s space and the child’s timing. I think it was important for this child that I could hold the experience of being left out, unwanted, helpless and especially powerless, and give him space and time to feel that he had the power to keep me waiting. Of course the risk in such a technique is of being experienced as masochistically colluding with his omnipotence: it needed vigilant monitoring on my part so that when it felt more self-indulgent on his part I could be firmer. I also want to mention another point concerning the strength of my voice when I coaxed Joseph to talk to me rather than to his imaginary (or delusional?) friends. I feel there was a kind of process of ‘reclamation’ at such moments, possibly because Joseph didn’t really believe his objects minded when he disappeared. Even the most loving and devoted parents, teachers and therapists can get very demoralised and give up a little under such conditions. Joseph did seem to appreciate my staying power, but only when I kept it mock-desperate, playful/needy: as soon as there was a hint of unprocessed frustration or directive pulling on my part, he retreated. (His teachers have independently developed similar non-

Downloaded by [New York University] at 03:54 14 August 2016 controlling methods with him.) I also think the drama in my voice got through to the developmentally delayed proto-speaker in him. (These active elements in the technique were informed by developmental thinking and also by awareness of the powerful hold of the repetitive preoccupations. The technique was by no means strictly psychoanalytic.) We have to find ways of helping these children not only to attend to us but also to sustain their attention, and emotionally heightened interest is central to this process. In conclusion, it is important to say that Joseph had dedicated parents, teachers and speech and music therapists, with whom I have liased regularly, so this has been a cooperative effort. I have simply tried to outline some techniques and Finding the wavelength 79

concepts that seem to have been helpful in my particular part of the work. Our task continues to be enormously difficult.

Note 1. Earlier versions published: A. Alvarez (2004) ‘Finding the wavelength: tools in communication with autism’, Infant Observation, 7 (2–3): 91–106 [(2006) ‘Die Wellenlänge finden: Werkzeuge zur Kommunikation mit autistischen Kindern’, in B. Nissen (ed.), Autistische Phänomene in psychoanalytischen Behandlungen [Autistic Phenomena in Psychoanalytic Treatments]. Giessen: Psychosozial Verlag, pp. 55–72]. Downloaded by [New York University] at 03:54 14 August 2016 This page intentionally left blank Downloaded by [New York University] at 03:54 14 August 2016 Part II Adolescence through adulthood Downloaded by [New York University] at 03:54 14 August 2016 This page intentionally left blank Downloaded by [New York University] at 03:54 14 August 2016 Chapter 6 The use of observation in the psychoanalytic treatment of a 12-year-old boy with Asperger’s syndrome1

Maria E. Pozzi

Introduction Asperger’s syndrome (AS) was defined in 1944 by the German psychiatrist Hans Asperger, one year after Leo Kanner’s description of autism. However, it has only recently received wider attention. The main diagnostic systems in use in the USA and Europe, DSM-IV (APA 2000) and ICD 10 (WHO 1992) respectively, have defined the syndrome as being distinct from autism. However, as the two syndromes share certain features, the distinctions between them are considered by some to be matters of degree (cf. Trevarthen 1998). The patient – whom I shall call Johnny – was diagnosed after one year of therapy as suffering from Asperger’s syndrome by the consultant child psychiatrist in the clinic where I work, a diagnosis having been requested by the patient’s school. The consultant child psychiatrist made her diagnosis by looking at the file notes, talking to the educational psychologist, meeting the mother and seeing the boy herself. She noticed Johnny’s difficulty in understanding social cues and the effect of his behaviour on others, his inappropriate behaviour in social situations and his low self-esteem and incapacity to maintain peer relationships. At the beginning of treatment, I considered my patient to have been in a ‘post-autistic state’. Meltzer et al. define this state as the outcome of a process of dismantling typical of autism, i.e. a passive process ‘akin to allowing a brick wall to fall to pieces by the action of weather, moss, fungi and insects’ (1975: 12–14). The process occurs by allowing the senses to wander and to attach themselves to the Downloaded by [New York University] at 03:54 14 August 2016 most stimulating, most colourful, warmest, softest objects available at a given moment, and by the suspension of attention. Both Meltzer et al.’s and Tustin’s frameworks have been of value in understanding the state of mind of patients like mine, which at the outset of treatment I was only able to intuit. I experimented during the therapy with a particular technique designed to reach and ‘to reclaim’ the patient (Alvarez 1992) which I describe here. My patient not only suspended his capacity for attention, but also probably never properly developed this capacity, one which Meltzer et al. saw as the string holding the senses together in a state of consensuality. The patient did not have 84 Maria E. Pozzi

‘common sense’ with regard to conventional seeing or to the ego functions of attention and imagination. I was often led to speculate about the early object relations of this child as well as to try to locate the deficit in his development (Alvarez 1992) within the schematic knowledge I had of his early infancy and childhood.

Psychoanalytic psychotherapy Children with AS are commonly described as not being aware of other people’s feelings, minds and even of their actual existence. (These traits are also used to describe autistic children, although it is clear that the two conditions are distinct and should not, in and of themselves, be confused.) They are depicted as being closed up, impenetrable, refractory, almost ‘refrigerator’ children, just like their mothers were unfortunately considered to be some fifty years ago. I have made extensive use of writings on autism to aid my thinking around the vulnerability of my AS patient. Reid and Alvarez (1999), for example, have affirmed that autism is a highly complex disorder for which mothers of autistic children should not be blamed. Child and adult psychotherapists and psychoanalysts (e.g. Tustin 1972a; Meltzer et al. 1975; Alvarez 1992; Mitrani 1992; Rhode 1998) have noted how mothers of autistic children struggle with a hard ‘shell’ that surrounds the very being of these children. These authors have depicted the vulnerable and terror-stricken creature who hides inside the shell and who has a ‘sixth sense about the state of mind of people who are close to them’ (Tustin 1994c), as well as ‘a deep sensory openness which is experienced as a bombardment of sensa’ (Meltzer et al., 1975: 20). These observations are pertinent to my knowledge and experience of Johnny. Johnny is a highly sensitive and intelligent boy who, beyond the isolation and the barriers he had erected between himself and the world around him, was capable of intense – albeit rare – outbursts of emotion and intelligent conversation. This was a ‘chink in the armour’ (Tustin 1992), which also permitted him to experience a flood of tears as early as the first individual assessment session. Such children are viewed as having to deal with an unmitigated sensory input before their neuro-psychological apparatus is equipped to cope with or process strong emotions (Meltzer et al., 1975; Tustin 1994c). As infants it is likely that they have Downloaded by [New York University] at 03:54 14 August 2016 experienced an assault on their senses from which they have protected themselves by erecting shells, barriers and encapsulations, and these have the effect of cutting them off from direct engagement in human relations. In the course of therapy with this boy, I was gradually and intermittently allowed to get beyond his protections by verbalising the minutiae of what I could see, sense and imagine to be the meanings of his behaviour, silences, gaze avoidance, secretive plays and wider behaviour in general. I constructed a number of flexible hypotheses about his possible states of mind and feelings as one does when, after having observed an infant and mother together, one tries to understand patterns of behaviour and likely underlying meanings. I also performed for The use of observation in psychoanalytic treatment 85

this patient certain auxiliary ego functions which had been dismantled or had never been there in him. All analytic work is based on careful observation and awareness of the patient’s behaviour, play and associations, and the therapist’s or analyst’s emotional and mental state while receiving the patient’s communication. In Johnny’s case, I also found it useful to verbalise my observations and speculations. This way of proceeding resembles more the kind of speculative thinking and reflection which take place in a mother-infant observation seminar, when the observer reports what he/she has observed in detail, rather than the interpretations made to a patient on the basis of the patient’s playing or verbal communication. The difference is that an interpretation is made on the basis of observed material, whereas speculative thinking and hypothetical linking is made on the basis of observing something less structured, such as a noise, a sound, a movement or a twitch, to which could be attributed many meanings. This way of employing something akin to an infant-observation technique was necessary, I argue, because Johnny spent long periods in his sessions without talking or playing at all. He rejected interpretations, seemed quite locked inside his body and appeared to me to be lost in his mind. It transpired that a less direct form of communication of the kind I have described had the effect of making a degree of contact with the patient’s infantile needs and at the same time lessened his sense of persecution. I give examples of this below. This adaptation of technique, which implies a certain amount of oblique communication with the patient, is something I have found useful in the treatment of children with elective mutism who are unable to play, as well as with some silent adolescents.

First encounter and early history My social worker colleague and I first met Johnny in a family session that also involved his mother, his two brothers aged 10 and 14, and a sister aged 8. He was a small, fair-haired boy aged 12 years and 9 months, with no striking features except for a particular walking gait: he tended to swagger from side to side rather than walking forward in an upright manner. In the family session, he giggled a lot with his younger brother and pointed with his finger at his temple, and then at his older brother and his sister, indicating that they were all mad. He interacted with Downloaded by [New York University] at 03:54 14 August 2016 his siblings in a relatively ordinary way and they played with the toys from the box provided. His mother had reluctantly accepted to come with all the children as she wanted only individual treatment for Johnny. Johnny was the second child, conceived just four months after the birth of his oldest brother. He had suffered from projectile vomiting from birth; he was not toilet trained until the age of five and all his milestones were delayed. ‘All wrong since he was a baby,’ said his mother, sounding tired and matter of fact. She could not breast feed him, as she was exhausted from the previous child. Johnny was well loved by the extended family, despite being ‘wrong, clumsy and awkward’, which had earned him the reputation of being: ‘Oh poor Johnny!’ 86 Maria E. Pozzi

The family had sought help early on, but was told that nothing could be done for a child like Johnny. They had moved from a distant part of the country, three years before the referral to the clinic, and father and mother had recently separated. Johnny attracted his teacher’s attention as a result of his low self-esteem and a tendency to cry for trivial reasons. Mother was advised to approach a child guidance clinic, where we met.

Comment It seems that a misfit between Johnny and the world had set in apparently from the beginning, when he could not keep his mother’s milk inside. He projected it out together with many of his own discomforts and terrors. It is possible that, as a result of this crisis, a fear of death by starvation or by evacuation had been around for both his mother and himself. She had been worn out and depleted by her first child and could not manage Johnny, who appeared to be easily distressed and highly sensitive to stimuli. Meltzer et al. consider that children with autistic- like disorders require something different from ordinary maternal care or a containing, ‘good enough’ mother (Bion 1962a; Winnicott 1960b). They seem ‘to require the mother to take in, contain and divest of pain the entire child, not merely a part’ (Meltzer et al. 1975: 22). Such infants seem to require superhuman mothers who could only exist in an ideal world. Johnny’s mother was certainly not ready for the birth of this baby, either psychologically or physically, and in our first session she spoke of the experience of his arrival in a cut-off way, unwilling to re-engage with those early days. Tustin spoke about a ‘shock absorber’ function of the mother which is usually lacking in the bewildered mothers of such children (1992) and seems to have been missing in Johnny’s mother. The overflow or spilling over of physical products and psychological tensions, to use Tustin’s expression, could be said to be reflected in Johnny’s difficulties in being fed and toilet trained. Johnny’s projectile vomiting and lack of sphincter control might be understood, from one point of view, as follows. On the one hand, here was a baby experiencing great difficulty in receiving, processing and using nourishment, as well as in disposing of its unusable residues. On the other hand, here was a depleted mother who seemed to have failed her infant in certain quite fundamen- Downloaded by [New York University] at 03:54 14 August 2016 tal ways. A fear of death, which I came to think the infant Johnny may have experienced as he evacuated his milk violently, may have turned into a form of nameless dread due to a lack of adequate containment (Bion 1962a). Bion noted how the infant projects his fear of dying into the mother, who under favourable circumstances digests, transforms and returns the projections to the infant in a more tolerable form. However, when the mother cannot perform this transforming, a-function, the projection is returned to the infant in the form of a ‘nameless dread’, i.e. charged with the unmodified original fear of dying and in addition with the mother’s own anxieties and fears. I was able to see considerable The use of observation in psychoanalytic treatment 87

evidence of this later in treatment when Johnny began to drop some of his autistic-like defences.

The assessment Johnny had reluctantly accepted to come to see me alone for an assessment for psychotherapy. He would have preferred to come with his siblings, in particular with his older brother, whom he looked up to in awe. He was late for his first session as he had forgotten to get ready when his mother picked him up from school. He sat silently with a very negative attitude through most of our three assessment sessions. He didn’t do anything nor did he let me engage with him. I tried to imagine and speak of his experience of being without his mother and his siblings, how he may have felt and I interpreted his worries at being alone with me and in a different room. He ignored it all and showed neither interest nor relief at my comments. After a silence, I decided to describe what appeared to me to be his feelings when he looked sulky, cross, sad and anxious: he said he did not understand me talking about feelings. I began to feel rather desperate about how to connect with him. It was after a certain amount of time had elapsed in the session, and a great number of ‘nos’ had been uttered, that he finally accepted something I had said but which I then forgot almost immediately. However, he continued to protest that he did not want to be with me and, since instances of contact were so fleeting, I decided to give him permission to leave if he wished to do so. I did not want to increase his pain by attempting in some way to compel him to stay. He did not go. I was struck when, as I later announced that it was time to go, he burst into a sad and depressed cry and refused to go. He pleaded with me to let him do a drawing. His immobility was broken by this experience. When he returned for his second session he looked more relaxed and told me he felt a little happier. However, a similar to and fro, as in the previous session, soon began to take place. All my comments had to be rejected and denied – this time in tears. Suddenly he began fidgeting on the chair complaining that it was uncomfortable. He scratched his legs, arms and back … then all over his body and it was clearly irritating for him and disturbing for me to watch. It was as if he could not stay inside his skin as this gave him such uncomfortable sensations, Downloaded by [New York University] at 03:54 14 August 2016 which I also began to experience in my skin and body. I spoke of how uncomfortable it was to be there, on that chair, in the room and also in his skin. He looked puzzled. After some time he asked me, over and over again, if he could play with the toys. He never did so, despite the various interpretations I gave him to address his anxieties, his need to have my permission, his desire to be well behaved. I eventually gave him a factual reply that ‘Yes’, he could play. But still he did not and repeated his question until the end of the session. In the third session he looked alive, sat in the usual armchair opposite mine and began fiddling with his hands and fingers. He showed some vague interest in my description of his fiddling. ‘They are getting together, stroking one another, 88 Maria E. Pozzi

hiding, coming back, going away … rather like Johnny and myself,’ I said and he continued this activity looking at his hands as if he was now interested in them and in my comments. This is how he spent most of that session and, when I suggested we meet again after the summer holiday, he declared that he did not intend to come back.

Comment The experience of a mother who tries to but cannot feed her baby because he evacuates what he is given was, I thought, being re-enacted in these sessions with me as a mismatch between us occurred. I felt that little or nothing was getting through to Johnny and, when he seemed to be reached fleetingly, my impression was that what counted were the rejections I endured rather than the content of my comments. He projected primitive and uncomfortable sensations into me, which were experienced at a psycho-physical level, and I was occasionally reminded of the work of a Jungian psychotherapist, Mathew (1998). She wrote on a physical experience (which she referred to as ‘body countertransference’), which allowed her to link up with deeply unconscious conflicts and anxieties – states of mind that her patient was not ready to express or to project. It seems that those conflicts and anxieties were communicated to the therapist by a flowing into her body, before they could be projected. As they entered the therapist’s body, then into her awareness, she began to be able to think about them in her mind. I have experienced a similar type of ‘body countertransference’ with Johnny, when something that was poorly organised or perhaps comprising some archaic aspects of his personality and mental productions were communicated to me, leaving me confused, unclear, irritable and uncomfortable in my own body. The mechanism by which this communication takes place might be thought of in at least two ways: first, as the mechanism of projective identification where what is projected is less structured and more archaic aspects of the personality are involved. Second, the mechanism may be akin to what Tustin called ‘flowing-over- at- oneness’ or adhesive identification. She saw this as a process by which the illusion of ‘primary union’ is maintained: the process occurs earlier than projective identification, implying some sense of bodily separateness between mother and infant (Tustin 1981: 80). I believe that this was the mechanism through which Johnny Downloaded by [New York University] at 03:54 14 August 2016 was relating to me at those times. The ordinary sequence of projection and introjection appeared to be inhibited or impaired, as though he had not yet gained a proper sense of separateness in certain areas of his personality. After his treatment had ended, I came across the writings of Corominas on archaic psychopathology and body–ego links in the development of a 5-year-old psychotic girl who had had cerebral palsy since birth. This girl never spoke but screamed incessantly and benefited from a particular form of containment, which Corominas calls ‘sensory-mental-bodily containment’. Her therapist, who was supervised by Corominas, transformed the child’s body language into mental, verbal communication in a way similar to the way in which I proceeded with The use of observation in psychoanalytic treatment 89

Johnny. She dramatised situations of togetherness and separateness, for example by joining her hands with the child’s hands then moving them apart. Sensations of togetherness and separateness were worked on in an attempt to transform them into emotional and cognitive states and to unblock the child’s development (Corominas 1986: 4).

Decisions Johnny’s assessment had taken place before the summer and, with hindsight, this was a mistake. To ask him to become involved only to then wait for a long time before returning was too much for a boy with his difficulties. In the assessment he had given me a true picture of how hard treatment would be and I was not at all sure therapy was the best way to help him. Moreover, his mother had been rather derogatory about psychoanalytic psychotherapy but in her desperation acceded to it for her son. I decided to offer Johnny once-a-week psychotherapy following both his mother’s insistence and that of my colleague social worker, who, at that time, had carried alive the hope to help him. The decision to offer once-a-week rather than more frequent treatment was taken for a number of reasons. First, the intense negativity and aversion expressed by Johnny made me question whether he would have given his inner consent even to once-a-week psychotherapy. More intense treatment would have disregarded the patient’s conscious message and, in all probability, would not have been sustainable or advisable. Johnny’s difficulty in communication and resistance to a closer relationship with me seemed to be entrenched in his personality rather than being the result of a restricted setting, and I felt that he would have fled had more intense treatment been offered. Practical reasons also militated against considering more intensive treatment. His mother or occasionally his father brought him to his sessions during the first year, but they had to travel a considerable distance and this necessitated making special work arrangements to manage the continuity and regularity of weekly appointments. According to my experience of working psychoanalytically with children in similar, very difficult psychological circumstances, it is possible to do helpful work within a proper setting using the transference and countertransference as essential interpretative tools. With such patients each session functions as a mini-week in Downloaded by [New York University] at 03:54 14 August 2016 itself, with a beginning, a middle and an end part to it. I bear in mind and interpret, as appropriate, the different states of mind of the patient, at the reunion after a week’s break, in the central part of the session, when some work on defences has been done and even patients who are difficult to reach can become accessible, and at the end of the session, when resistances and closing down can occur.

The beginning of treatment After the summer holiday Johnny came with his mother to the clinic without difficulty. During the first two terms, I experienced innumerable rejections from 90 Maria E. Pozzi

him, my comments being mostly answered with ‘No’. He told me that he had no worries or problems: it was other people who had problems. He called me Ms Potty and said that I was mad, not him. He easily gave up talking or made it impossible for me to understand his strong dialect which he usually only spoke at home, as his mother had reported, and during the assessment. Later in treatment, he would only speak standard English and this became a sign for me of greater engagement. In these early sessions my interpretations were mostly rejected or reacted to – even before I could end a sentence. I experienced regular hopelessness and desperation about how to reach him. I decided to resume the approach I had employed in the assessment. As he sat on the armchair opposite mine, hardly doing anything for long periods of time, I described to him what I saw, in a manner akin to being present at a baby observation. I did not address his actions or feelings, such as: ‘Johnny is talking, is feeling …’ as he rejected this, but I did say: ‘Johnny’s mouth is moving; Johnny’s lips are saying something; Johnny’s fingers are hiding …’ I spoke to him at what could be thought of as a part-object level by addressing the actions of specific parts of his body. Gradually he became interested in this way of communicating: he touched his lips, looked at his fingers moving and listened to me. Eventually he asked me what I was doing and why I was speaking like that. I replied that I was rather like a mirror reflecting his body. In the following session he brought a mirror. He was annoyed with me and protested: ‘See, I can’t reflect myself in you, only in the mirror.’ However, by the end of that session he looked more alive and became interested in looking at his eyes in the mirror. In a later session in therapy, he became interested in lights, smells and noises. He closed his eyes as he looked at the sunny window; he twitched his nose and perked up his ears as he heard a noise from outside. I decided at this point to speak of feelings, not only of body parts, in order to see if Johnny might be capable of connecting the two, within our relationship. I said that his eyes were bothered by, and did not like, the sunlight; that his nose was bothered by a funny smell; his ears seemed bothered but also interested in a noise. This seemed to affect him as he looked intently back to the window, twitched his nose or listened to noises. He gradually became more interested and involved in these experiences. He was intrigued by a new perception of his awareness of his senses and of their functions: seeing, smelling Downloaded by [New York University] at 03:54 14 August 2016 and hearing. I think, with hindsight, that I was acting as a kind of ‘incubator’ in which this ‘psychological prem’ was beginning to achieve some form of basic integration which had not been possible in his infancy, to borrow Tustin’s imagery (1981: 195).

Short-lived play and communication This section describes a period when Johnny was able to be more verbally communicative, cheerful and playful. This usually occurred after working through the difficult beginnings of sessions, when he would sit opposite me and hide The use of observation in psychoanalytic treatment 91

behind his school bag placed on his lap. He would eventually emerge from his distant state and relate to me, often using the ‘part-object’ technique I have described. In one session, he wanted to make a parachute and asked me if he could cut the cloth that was inside his box of toys. I interpreted his need to have my permission to be a good boy and that he might be worried about cutting and spoil- ing the cloth. He ignored my words and insistently repeated the same question. When I included a factual reply that he could cut it, he did not cut it but used it all to make the parachute. The parachute was fragile at first and the doll-man tied to it fell and ‘died’. I described this sequence to Johnny as it occurred. He made a stronger parachute that could fly for a little longer. Johnny’s repeated questions and refusal to respond had left me feeling exasperated, rejected and puzzled, and I wondered whether this was my countertransference experience of confused, frustrated feelings that he had projected into me. Then, as the parachute got stronger and landed without crashing, and his uncooperative position diminished, I thought that something had percolated through Johnny’s mind as he was learning to fly and land his toy relatively harmlessly. In another session, he set up a theatre play where a family was going to the zoo. Dad was also there and they had a good time. He responded to my interest in his play and to my taking the role of a member of the audience describing what he was portraying. However, when I said this was the family he wished to have, this happy moment was broken. He collapsed into depression, stopped playing, picked bits of dry, hard mud from the soles of his shoes and threw them at me. I said he felt mad at me as perhaps because he thought I had attacked him with bad, mud/pooh-like words, which spoiled his happy family play. Johnny fell into a state of persecution and guilt and implored me not to swear because it was bad. I tried to calm him down, to take in his fears and said it was all right to use the word ‘pooh’ and nothing would happen but perhaps a thought or voice in him did not allow him to speak like that. He showed no sign of interest in this. However, as the end of that session approached, he repeatedly and anxiously asked me to forgive him. He chastised himself, promising that he would never throw mud at me again and that he had learned his lesson. He acted as if he had committed a crime and was now expecting far worse punishment and retaliation from me. I was struck by this exaggerated reaction, which was not at all propor- Downloaded by [New York University] at 03:54 14 August 2016 tional to his attack, which, in reality, had been rather mild. In another session, Johnny played with animal poachers who kidnapped mum and dad wild animals, while cubs and small animals climbed into a plastic container and then went to rescue the kidnapped parents. During the rescue operation, the container nearly fell down, but was in turn rescued by other animals. Johnny was playing on his own and was cut off from me. A wave of sleep suddenly clouded my mind and I felt barely able to interpret his anger at feeling robbed of the big animals/parents in his play and of myself at the end of each session. The struggle to climb back to the relationship with the ‘parent-therapist’ after a gap of six days was fraught with dangers, such as feelings of falling apart, 92 Maria E. Pozzi

but it was hard to know how much of my thinking got through to him, as he appeared to ignore me. However, he eventually started to pack and repack his school bag, looked for his cap frantically then said he might have lost it at school. The session was over, and he left but returned immediately to say ‘good bye’, which he had forgotten to say. I was surprised, as he had never acknowledged the end of sessions and I wondered whether he was more in touch with a feeling of loss (perhaps linked to the loss of his father, his therapist and his cap). After this session, his mother told me by phone that he went straight to a sweet shop, stole sweets, was caught and was given a warning by the police. It seemed likely that he could only bear the feeling of loss for a very short time. In the following session, he hid from me anxiously, his head inside his school bag, and said he was dead. He ate sweets and mimicked his hands being stuck with glue and asked for help to unstick them. I said he was eating lots of sweets then playing at being caught, handcuffed and punished, perhaps even to death, and he needed my help. He asked if he could eat the sweets and I did not prohibit this but spoke of his anxieties. Still from behind his school bag, I heard him whisper to himself that he was never again going to eat sweets and was very, very sorry. He got into a delir- ium-like, muddled state and – still in a whisper not directed at me – pleaded intently for forgiveness for eating sweets and promised to stop. I thought he was transferring his guilt for having stolen sweets from a shop – which he never volunteered to tell me – to a guilt at eating them in the session. In a virtually psychotic way, he was now ridden with persecutory guilt, anxiously wanting to make amends.

Comment on Johnny’s persecuting superego Johnny’s harsh superego, based on the ‘law of talion’, was beginning to manifest itself. In the session where he portrayed a happy family at the zoo, Johnny threw mud at me in reply to my comment on his wish to have such a happy family. I wondered whether he experienced my interpretation as a concrete attack because it reminded him that his real family was not as he wished it to be. Alternatively, he may have felt that I had not recognised a moment when he experienced a good family inside him and in the transference. Downloaded by [New York University] at 03:54 14 August 2016 The sequence of the play with animal poachers, the stealing of sweets and the session where he repented excessively could be understood as being driven by early persecutory guilt which could only be assuaged by actual punishment. Freud wrote about delinquent adolescent-like acts which were also performed by adult patients and which relieved them of oppressive feelings of guilt. The person did not know the origin of such guilt, which was present before such acts, ‘and after he had committed a misdeed this oppression was mitigated. His sense of guilt was at least attached to something’ (1915: 332–3). I think Johnny was in the grip of a similar sense of guilt and confusion which in all likelihood had origi- nated in his early infancy. The use of observation in psychoanalytic treatment 93

Comments on stealing, deprivation and links with separation Winnicott had a deep interest and understanding of the antisocial tendency and its relation to deprivation and separation. ‘A child who steals an object is not looking for the object stolen but seeks the mother over whom he or she has a right’ (1956a: 125). It is a loss that occurs ‘at a stage in the child’s or infant’s emotional development when a mature reaction to loss cannot take place. The immature ego cannot mourn’ (p. 132). Winnicott refers to the time when the libidinal and aggressive drives achieve fusion. Klein (1935, 1948) saw this time when the integration of the ‘good’ and ‘bad’ breast or good and bad mother occurs and a whole figure is seen as owning both goodness and badness. The child begins to feel the loss, to be aware of the absence of the maternal object and to tolerate this absence temporarily, if the child has received good enough mothering and has internalised a good object. Johnny had received some experience of reverie, metabolisation of his projections and understanding during these first two terms of psychotherapy. This good experience may also have reflected some nurturing aspects of his early environment. The episode of stealing sweets had occurred as the Easter holiday approached and Johnny responded as if some good experience had been interrupted and taken away from him. It is a sign of hope, Winnicott wrote, when the child manifests this antisocial tendency as he/she hopes to get back and regain what had been taken away (1956: 122). In the session in which animal poachers appeared and stole big zoo animals, Johnny may well have felt robbed of his sessions and of his therapist. Just before the Easter holiday he took to hiding in a cupboard, refusing to go at the end of sessions. I felt bad as I wrenched him away from me, trying at the same time to free his octopus-like grip from the furniture he clutched on to. No verbal interpretation about his wishes to stay or his anger at having to go or my badness as I sent him away had any effect on him. Once he went to sleep right at the end of a session saying he ‘wanted to sleep for another hour … for a week, ten weeks, a hundred years’. He agreed that he wanted to stay forever. However, by the following week he had – once again – barricaded himself behind his school bag and cut himself off

Downloaded by [New York University] at 03:54 14 August 2016 from me. A strong attachment to me and to the sessions went together with an equally strong rejection and apparent disinterest as a defence against his feelings about gaps. It was like an unpredictable relational seesaw which later on would become rather more predictable. On our return after Easter, a powerful resistance was to burst out suddenly and violently.

The Easter break: a new technique is required When Johnny came back after two weeks, he had greatly deteriorated. He took to coming to his sessions very late and often sat in the waiting room for the 94 Maria E. Pozzi

remaining time, refusing to leave it. When he eventually came to the therapy room he fell asleep behind his school bag and slept for whole sessions. Despite my waking him up and interpreting about the holiday break, his need to control and his projections into me, he ignored it all. When he did not sleep, he was angry and provocative, argued and battled with me over anything or kicked, shouted and threatened to ‘do me for assault’ if I held out my hands to protect myself. Alternatively, he mocked me and spoke contemptuously, parroting my voice. In the countertransference, I experienced anger – an anger that I felt sure reflected his own and which he refused to tolerate whenever I tried to address his feelings. He continued feeling highly persecuted until he eventually clammed up completely. My technique of reaching him was no longer successful during this phase and I had to find new ways of working with him. Interpretations of his unconscious conflicts, anxieties and defences, which would have reached a more neurotic patient and which from time to time had touched him, now failed, perhaps because of their being too directly focused on his heightened affective states and therefore too persecutory for him. There was a definite limit to how much Johnny could bear being reached, and this was reflected in the fact that a lot of psychoanalytic processing was taking place at this time in my own mind rather than his, since he spent long periods hiding behind his school bag, saying little, doing little and rarely responding to my interpretations with words or clear behaviour. What was always encouraging and interesting about working with Johnny, however, was his capacity to evoke and inspire in me new ideas and imaginative thinking which allowed me to find ways to relate to him, his barriers and defences notwithstanding. I thought that this was a sign that he was not in an autistic, deadening state that kills hope and enterprise in the therapist. I found myself feeling more creative and producing new ideas to a degree that surprised me. It was as though his creativity flowed into me through a type of unconscious mechanism, which I have tried to clarify earlier in this paper. I believe that what flowed into me, and left me rather unaware that it was coming from Johnny, was not a clear and specific aspect of his personality but, in his case, a preconception of a form of liveliness or creativity, as Rustin (2000) commented to me. My technique now consisted in initially developing a dialogue, first with an imaginary friend, later with Johnny himself. I described to this friend what I could see, imagine or hear Johnny was doing behind his school bag and the ‘friend’ Downloaded by [New York University] at 03:54 14 August 2016 replied to me. ‘Listen to that noise … is it the wind?’ ‘No, it’s a bird outside.’ ‘No, it’s a person sleeping.’ ‘It’s a child, a boy.’ ‘Yes, he must be fed up and cross.’ ‘I think it’s Johnny, he’s fed up!’ ‘He didn’t want to come to his session today!’ These dialogues began to arouse Johnny’s curiosity, again I think because he experienced them as less persecuting. He pushed his bag aside, looked straight into my eyes – which was rare – and asked to whom was I talking. I explained that I was talking to an imaginary friend and – in case he did not understand the concept of imaginary friend – I added that it was like two friends talking to each other or a mother and a father talking about their child. He was clearly touched by this type of communication and seemed to The use of observation in psychoanalytic treatment 95

understand the concept of imaginary friend, and he became involved again with me through playing and talking, even if only for the last part of his sessions. Occasionally, I spoke as if I were Johnny thinking. ‘She’s a bore! She wants to know what I’m doing. She’s nosy; she shouldn’t say that she can hear me eating sweets. I feel bad if she says I’m eating sweets.’ Once he responded: ‘No, I’m not reading!’ ‘Yes, I feel bad if I eat sweets.’ At other times I gently mirrored his noises, for example breathing, chewing, gulping, yawning, turning pages, writing, which he produced hidden away or tucked inside the protective shell of his jacket. This also caught his attention and encouraged him to interact with me, even if usually only through disagreement and protest.

Comment Sweets seemed to stand for a prototype for Johnny of some desired, oral gratification that he felt he was not allowed to have or receive generously. They seemed to represent a ‘good and sweet breast’ which he seemed to have had briefly but lost and needed to steal back in a secretive way, hence feeling guilty and persecuted. Rhode (1998) writes of the baby’s understanding of ‘the mother’s emotional unavailability – her mental preoccupation – as being the consequence of her physical occupation by someone else’ (p. 473 in the German version). The presence of the ‘other’ had been a constant in Johnny’s infancy, a presence which had deprived him of his mother’s full attention. Johnny had fluctuated between sessions when he needed autistic-like defences (Tustin 1986b) to shut out the persecuting, intruding and terrifying world of others, and sessions when he talked, played and appeared more at ease with himself, with me and with the world at large. The adaptations of technique paralleled roughly Johnny’s stages of emotional development: from a ‘part-object’ form of relating, when I addressed parts of his body and their associated meaning, to a whole-object relation when I spoke of Johnny himself or myself doing something or having feelings. Then a third person was introduced – an imaginary friend or father figure with whom I had a dialogue about Johnny. This could be seen as a reference to a ‘combined object’ (Klein 1952) which Johnny was gradually able to accept and be curious about. Downloaded by [New York University] at 03:54 14 August 2016 The last phase of therapy In the fifth term of therapy – from Christmas to Easter – I saw little of Johnny. He missed sessions, came late or was unreachable and slept. His ups and downs continued and I never felt we reached a stable plateau. Johnny was occasionally suspended from school; these disciplinary actions were, I suspect, in part because the school authorities had not properly taken in that he was a boy with special needs. He was also found by the police wandering on his way to the session, lost both in the streets and inside himself. Anger, defiance, stubbornness, rebellion, provocation were now the principal features of his sessions but Johnny seemed 96 Maria E. Pozzi

unable to take on board such states of mind and feelings. Plans for him to go to a residential school for children with Asperger’s syndrome were being made and he seemed to look forward to that, despite his anxieties and uncertainty.

Looking: a source of anxiety In the ups and downs of his moods, an interesting theme had emerged which, in the last few months of treatment, became more explicit. Johnny had told me, in a moment of sincere contact with me, that he did not like looking at people’s eyes. I tried to explore if he was scared, angry or fed up if he looked at people’s eyes, but he did not know. In my attempt to understand him, I wondered aloud whether perhaps, as a small boy, he had looked at his mother’s face and eyes and sensed that she was tired and busy, and felt as if she could not see him. Perhaps he wouldn’t have liked that and now he preferred not to look at people’s eyes. I often speculated aloud about his early days in sessions as a means of composing a possible narrative of his early life which he seemed to lack in the way children subject to developmental delays exhibit. He would listen silently and noticeably did not protest, and I felt he was somewhat interested. In a session before a long break, Johnny looked fed up and harassed as he walked from the waiting room along the corridor. In the room he slumped, as usual, into the armchair and hid behind his school bag. There was a long silence: I said that perhaps he was hiding his feeling of being fed up. ‘No, I’m not fed up,’ he replied. After a long silent spell he peeped from behind his school bag and asked me, ‘Can you see my eyes?’ ‘Can you see my face?’ ‘Can you see me?’ He was still hiding but was able to see me between the straps of his bag. I said, ‘You can see me and are not sure if I, too, can see you.’ After a silence and more of the same peeping game, I added, ‘You want to see me without being seen.’ After another long silence and immobility on his part, I heard him saying, ‘Going to sleep.’

A: You seem tired. P: No. What will you do if I go to sleep? A: [ I decided to reply factually to avoid another familiar impasse.] I’ll wake you up. P: I’m not going to sleep. Downloaded by [New York University] at 03:54 14 August 2016

However, within minutes, he fell asleep behind his bag. I woke him up by calling his name. I allowed some silence to elapse before I told him that I had brought a note with the dates of the coming holiday.

P: [ From behind his bag] I cannot hear and see … I don’t hear with my nose, mouth, eyes. A: I’ll tell you the dates and I will show you the paper with the dates written on it. P: [In an annoyed tone] I can’t talk and hear at the same time. [Pause.] I can’t hear and see. I can’t see and talk. The use of observation in psychoanalytic treatment 97

I said it was hard to talk about holidays. He moved his bag aside, stretched one arm towards me and reached for the note with the date. He looked at it and said he was not coming next week or in three weeks’ time. He was going on a school trip and … he did not finish his sentence. I said that he was giving me his holiday dates and this was making him feel better about mine. Then he blew air into a pen, dropped coins, tore bits of paper off the holiday note and let them fall from his hands. He conveyed to me a feeling of being in pieces and dropped by me. I said this to him and linked it with not seeing each other next week and also later on. It was the end of the session and he did not come during those weeks for the reason he had given.

Comment We can see from the above exchange the impact on him of knowing that he would miss sessions and also of the announcement of a long holiday. The peek-a-boo game he played was, I think, his way of attempting to master the difficult experience of separation from me. In this game, which is typical of a much younger child, he was trying to take control of seeing and looking at the other person, thus doing something we knew he had not liked before. Moreover, I found particularly interesting his graphic awareness that he could not coordinate various sense organs in a harmonious way, rather like infants who do not yet have the capacity to coordinate movements and sensory activities. For Bion (1962a), a ‘common sense’ is an essential mental act ‘which appre- hends objects in their multi-faceted aspects as opposed to neuro-physiological events’ (Meltzer et al. 1975: 13). However, for a common sense to develop in Bion’s terms, the nursing infant has to have an experience where the senses come together in a gratifying and containing feeding situation. Andersen (1992) wrote about this in her intensive therapy with a three-year-old boy with autistic features. She referred to a good feeding situation, where the baby is held by the nipple in the mouth, by the flow of milk in the stomach, by the eye contact with the mother and by the physical holding of the baby in the mother’s lap. These sensory experiences, simultaneously coordinated, develop the cohesion of a psychological common sense and a sense of oneself as a recipient of those profound physical and psychological experiences. For Bion, common sense implies that the senses Downloaded by [New York University] at 03:54 14 August 2016 are in harmony and support each other, as we can imagine they are in the good experience of the baby at the breast (1992: 10). Johnny did not seem to have achieved a harmonious coordination of senses as a small child and now he could not perform adequately two activities at the same time, such as hearing and seeing or talking and hearing, without much anxiety.

Loving looks In another session, he said again that he did not like eye contact and asked me if I did. ‘Yes, it’s nice,’ I answered. ‘Why don’t you marry “eye to eye”?’ he asked. 98 Maria E. Pozzi

I suggested that he was scared of eye contact because it was too nice and perhaps exciting. He then initiated guessing games, quizzes and puzzles with me and looked straight into my eyes. When I guessed names or numbers correctly, he would look up at me at times, from his sitting position on the floor, with a radiant look, in awe, reminiscent of a blissful infant at the breast looking up at mother. It felt like a moving and aesthetic experience for both of us. I was reminded of Meltzer and Harris’s (1988) thought on the aesthetic conflict when Johnny looked embarrassed, blushed and told me not to stare at him. This loving gaze could be too much for him. Perhaps his looming adolescent sexual feelings may also have been emerging at that time. His loving feelings towards his object, i.e. his therapist in the transference, became more explicit when he proposed that we read the story of Romeo and Juliet from a book he had brought. I chose the part of Juliet and he chose Romeo. Having tolerated, named and helped to transform a good deal of his rage, aggression and truculence towards me in an earlier phase of therapy, Johnny now seemed able to access more of his loving feelings towards the object.

A boy with a heart Johnny was to move to his new boarding school after half-term. He had visited the school and felt at home there. This he told me in the session following the visit and which was to be our last session. He had brought a plastic cube with small metal balls inside, which had to be fitted into tiny holes by gently changing the orientation of the cube. He managed this quite skilfully and I spoke of this ability to make them fit, of the home that he felt he had now found in the new school and also in his sessions with me. He nodded. He then read two poems that he had written at home: he wanted me to have a copy of them. The first one was about a boy, himself, who was apparently not brainy or bright but who had a heart and feelings. The second poem was about nature, the dawning day, the rising sun and then the rain. I was moved by the depth and the clarity of his feelings and that he had been able to access and express these in poems. I said he was telling me a great deal, not least that he had discovered a capacity to have a heart and feelings. He looked at me with a transfixed stare and said – holding his breath and Downloaded by [New York University] at 03:54 14 August 2016 emotions – that he loved me and would miss me. Then he hid his face as he blushed with what seemed to be a mixture of pleasure and embarrassment. He took the poems with him and this was the last time I saw him.

Conclusion Johnny, aged 12, was taken to see a child psychotherapist when his feelings of being at odds with himself and the world had virtually stopped him from learning and socialising. He was extremely persecuted, isolated and withdrawn behind a protective shell, especially when he was outside home. In therapy, he was The use of observation in psychoanalytic treatment 99

difficult to reach, felt easily intruded upon and seemed empty of thoughts or memories. However, I felt that he was able to let some of his internal world flow into me as I found myself inspired, enriched by his ideas and impressed by his intuitive understanding. He slowly opened up through a modified technique that I gradually evolved through my work with him. He went through a phase of anger, aggression and truculence that was, on the whole, out of character with his hypersensitive, meek disposition. The understanding and containment of this phase paved the way to eventually meet a ‘boy with a heart’. The end of his therapy was precipitated by admission to a special boarding school for children and adolescents with AS. This final stage ushered in an attachment to the therapist that had been anticipated in the past by Johnny’s reluctance to leave at the end of sessions. Such attachment was a mixture of tender, loving feelings and embar- rassing erotic responses. Children with AS seem to me to struggle with a sense of there being a void at the depth of their existence; their loving, hopeful and lively feelings are consequently greatly impaired. The variation on an infant-observation technique used to reach and to communicate with Johnny helped him to articulate some sense of himself as a boy who could experience loving feelings. This was an achievement for a child who had been dominated by hatred, negativity and despair that had undermined any therapeutic effort. The sudden appearance of positive and loving feelings, at a time when we were due to stop therapy, left me somewhat perplexed. When I had previously kept some distance from Johnny and engaged in dialogues with imaginary people, he had been able to reach out for the object and to be curious about it. Rhode (1999) has suggested that this was a safe distance which may have reduced his fear of being trapped and sucked in, as had occurred in the first assessment sessions when I gave him permission to leave. Only then could he stay. It is quite possible that his capacity for loving feelings re-emerged because of the imminent end again providing a distance and a safe space to allow himself to feel. Downloaded by [New York University] at 03:54 14 August 2016

Note 1. The original version of this chapter was awarded the 3rd international Frances Tustin Memorial Prize and was presented at the FTM Lecture in Los Angeles in 1999. It was first published in 2003 in the Int. J. Psycho-Anal., 84: 1333–49. Chapter 7 Aspects of the body image and sense of identity in a boy with autism Implications for eating disorders

Maria Rhode

It is a common observation that anorexic patients often have a body image that can be unrealistic to the point of being delusional. Someone who is emaciated to a life-threatening degree can still think of herself as fat and perceive professionals’ attempts to save her life by getting her to eat as evidence of a hostile determination to make her ugly and unattractive. Anorexics seem to be preoccupied with the space their body occupies even more than with how much they weigh (which may indeed be experienced in terms of fitting into the space below a particular line on the scales). Space to be occupied may not feel like the person’s own legitimate space, and it is often unclear into whom any food that is eaten will go. For example, an anorexic patient described by Rey (1994) felt that she contained both a mother and a baby in a mutually destructive relationship, and that she had to starve ‘herself’ in order to kill the mother and free the baby. Sheila MacLeod (1981), in a book written after her recovery from anorexia, emphasised that pregnancy was the one time when she experienced none of her usual panic on approaching the weight of eight stone. It is as though the fact of physically containing a baby gave her permission to expand. Joyce McDougall’s patient Georgette, who had suffered from anorexia as well as from a variety of psychosomatic ailments, was preoccupied with issues concerning skin as a body boundary – both her own and her mother’s (McDougall 1989). Georgette experienced herself as sharing completely in the analyst’s life, to the point of talking about ‘our husband’. In the course of treatment, her inability to eat shellfish was resolved when she associated their smell with that of the paren- Downloaded by [New York University] at 03:54 14 August 2016 tal genitalia. Such accounts call to mind the commonly reported confusion seen in anorexics between eating and sexual maturity, between food and babies. However, they also highlight fundamental issues of identity in terms of whose space is occupied by whom. Children with autism, like anorexic patients, are preoccupied with issues concerning their identity and survival; again like anorexic patients, they may attempt to cope by exerting complete, delusional control over their environment. When this is not possible, their sense of helplessness and panic can be overwhelming. Frances Tustin (1981, 1986a) has discussed material of anorexic patients which she felt showed pronounced autistic features. More recently, Aspects of body image and sense of identity 101

Barrows (1999) has noted the importance of such features in a young woman with bulimia. From Tustin (1972a) and Meltzer et al. (1975) onwards, autistic children’s body image has been described as bizarre, unstable, two-dimensional, subject to a binary split (Tustin 1981; Haag 1985). In this chapter, I wish to consider a number of vignettes to illustrate different ways in which Anthony, a boy with moderate to severe autism, experienced his body. Although he did make considerable progress during treatment, that will not be my focus here, nor shall I attempt to describe how his body image evolved over time. His sense of identity appeared to be very unstable, often varying according to the physical space within which he found himself, and thematic links in his material emerged very gradually. Inevitably, such a thematic presentation must provide a picture of Anthony’s therapy that does not do justice to the repetitions, the sense of confusion and the difficulty of forming any clear impression of who was doing what to whom. Part of this difficulty was a function of the obscurity of the material and of my own shortcomings; part, I believe, was a function of the instability of Anthony’s sense of identity, some aspects of which feature in the material I shall discuss. Though some of the patterns which emerged appear to me suggestive, much must remain speculative, as must the links I shall later propose with material from patients with eating disorders.

Between the parents At the time of his referral at the age of six, Anthony’s teachers described him as highly intelligent but extremely withdrawn. Except for attacking other children, he took virtually no notice of other people; when he spoke, it was in a repertoire of voices not his own, and his speech did not appear to be communicative. He was referred urgently just before the expected birth of a sibling, as his parents and teachers were seriously worried by the suddenness and lightning speed with which he attacked other children whenever he felt upset. If his parents took their eyes off him for a moment, he would damage the house and threaten his younger sister with a knife. In a family session, he sat wedged between his parents, smiling in a way that they described as happy, but which appeared to my Downloaded by [New York University] at 03:54 14 August 2016 colleague and to me to be strongly tinged with cruelty. Although Anthony’s parents were loving and concerned, and realised that he needed help with his destructive behaviour, it appeared to be difficult for them to recognise and respond to some of his emotions.

Birth and bodily mutilation Cruelty of more than one kind was an important theme from the beginning of Anthony’s treatment. He enacted over and over again what looked like the catastrophic birth experience which Tustin (1981) described in ‘Psychological Birth 102 Maria Rhode

and Psychological Catastrophe’: falling head first off the desk into the void, he would struggle to reach the safety of a chair. As he fell, he clutched the drawstring at the waist of his tracksuit bottoms as though it were an umbilical cord that was supposed to stop him from falling, and twisted his mouth into a tortured, distorted shape. It was as though the broken mouth that Tustin (1972a) has described as being the autistic child’s essential experience of bodily separateness were the immediate concomitant of his tortured ‘birth’ from the desk and the associated loss of the umbilical cord joining him to the mother figure. In turn, Anthony inflicted tortures on the doll family, twisting their heads and limbs until they came off. The doll’s house would be balanced precariously on the edge of various pieces of furniture, only to be lifted high in the air to the accompaniment of menacing growls, and spun round and hurtled groundwards until all the furniture fell out. Anthony muttered, ‘Dorothy’ – presumably an allusion to the film ofThe Wizard of Oz, in which Dorothy’s house is lifted into the air by a tornado. I understood this both as Anthony’s way of conveying the chaos of his experience of bodily separateness, and also as the representation of his attacks against supposed inhabitants of a mother-house, on whom he was visiting his sufferings just as he had on the doll family. It was difficult at this point to judge how far these attacks went beyond a communication of his own experiences – whether his cruelty remained a matter of his behaving like a cruel internal figure, or whether he had come to enjoy it for its own sake. What was certain was that Anthony did not expect to be able to communicate his experiences to another person without having a catastrophic effect on them. For example, early on he cut deep, cruel gashes into the sides of a plastic beaker; months later, he filled it with water and described the leaks as ‘Lady crying’. Such a leaky, crying internal object provided him with no support. When he placed the beaker in the dolls’ house, he showed me repeatedly how easily the house tipped off the edge of a chair. It was as though his own tornado- like experience of birth had been cruelly transmitted to an object – the plastic beaker – that had been damaged in the process, and the whole sequence had been internalised and thus perpetuated. It is interesting that Anthony was in fact hypersensitive to the sound of other children crying. This was often the trigger for his attacks on them – probably, it seemed to me, as much with the aim of trying to reassure himself that his actions were not responsible for the crying as with the Downloaded by [New York University] at 03:54 14 August 2016 aim of getting it to stop.

The cruelty of the impervious combined object Tustin (1981a) proposed that physical birth could be experienced as a psychological catastrophe if the mother were unable to provide emotional containment of the infant’s experience in the form of what she called a ‘mental uterus’. Anthony seemed to experience being on the outside of anything or anybody as meaning that his body was under threat and that no one noticed or understood this feeling. He often banged violently with his knees into the metal radiator, Aspects of body image and sense of identity 103

producing a loud clang. His knees could of course not penetrate the metal. Instead, they were forced wide apart, as though his legs might be broken off at the hip joint. Such fears of being dismembered or ‘disjointed’ are frequently met with in children with autism (Haag 1985, 1991b). Similarly, the shut door on the dolls’ house seemed to be pushing Anthony into space. He would ring the doorbell, pleading, ‘Pleeease help me’ with a falling intonation as though he were dropping off the edge, but without eliciting any response from inside the house. Anthony appeared to blame the mutual absorption of a twin-like parental couple for this imperviousness to his experience of falling and of being mutilated. Balancing a cow on its muzzle on the surface of a mirror, he pointed at the reflection and said, ‘Mummy and Daddy’. He spent much time on the telephone, speaking in an imitation of his mother’s voice to someone he addressed as ‘Darling’ while ignoring me completely: he vividly conveyed how totally this conversation between the parental couple obliterated anyone who was not part of it. At other times, Anthony smiled, enraptured, at the telephone receiver which he held as though it were either a mirror or a microphone. He looked as though he were a star in love with his public and basking in their adulation, or a narcissistic mother receiving the admiration of an adoring husband. Indeed, I was informed that he came into his own on any occasion that involved performing. It seemed then that Anthony experienced the parents – who in reality were devoted to him and concerned for his welfare – as uniting against him to form a cruel and impervious combined object. Before a holiday break that came sooner than expected because of unavoidable external factors, he impassively and methodically cut body parts off the toy animals – muzzles, tails, ears, paws or hooves. The animals all pleaded, ‘Please don’t do this to me,’ but the process of mutilation continued as though no one had heard them. After talking to him about this at length, I eventually stopped him: not to do so would have felt like colluding with the ethos of the concentration camps. Anthony appeared to attribute different aspects of this experience of mutilation to the maternal and paternal elements of a cruel parental couple. The active cutting off of body parts seemed to be the function of the father, represented by such figures as the evil Darth Vader in the Star Wars series who cuts off his son Downloaded by [New York University] at 03:54 14 August 2016 Luke Skywalker’s hand, or by the Giant in Jack and the Beanstalk who threatens Jack with being killed and devoured and whose menacing growls Anthony often adopted. The mother-figure, on the other hand, seemed to express her cruelty primarily by ignoring the victims’ pleas. Anthony’s mother, who battled coura- geously to cope as cheerfully as she could with circumstances that were often overwhelming, occasionally said ‘Yes’ in a way that could have been misinter- preted as though she were humouring someone. He once produced a startlingly accurate imitation of this tone of voice and then commented, ‘Cruel mummy’. It appeared that the cruelty that featured so prominently was both to do with Anthony’s experience of bodily mutilation and with what he mistakenly felt was 104 Maria Rhode

the wilful ignoring of this experience by an impervious mother-figure completely taken up with a ‘darling’ husband who was her own mirror-image. Like Tustin’s patients John, David and Peter (Tustin 1972a, 1981, 1990a), Anthony was preoccupied with getting hold of a powerful ‘extra bit’ which he seemed to think adults possessed, and which made them immune to such terrors. Possession of this ‘bit’ – he sometimes felt this was my watch, ring or scarf which he would try to grab – would presumably make things all right. This was a magical solution, and was ultimately unhelpful as it inevitably left him feeling that he had no proper foundation, and that his object was either damaged (the leaky beaker) or vengeful (the giant-father).

The tripartite object: the nature of the link between the parents Shortly after a holiday some two years into treatment, Anthony began to insert his hand down the crack between the seat and back cushions of an armchair while muttering about a one-pound coin. It took me some weeks to realise that he was referring to a current advertisement for McDonald’s. This showed a burger bun, opened up to look like an armchair, with two burgers as cushions, one lining the back of the chair, the other the seat. The pound coin – advertised as being all that was needed to buy this Double Burger – was shown poking out between the two burger ‘cushions’. Anthony behaved as though he felt it to be a powerful, magical object, like my ring or scarf, which would procure the possession of twice as much burger as normal. At the same time, the structure of the Double Burger called to mind the ‘Mummy-and-Daddy’ bull-and-cow reflected in the mirror, who seemed hinged by their muzzles like the back and seat of the chair. I wish to emphasise several aspects of this tripartite model. One is the similarity to the position, wedged between his parents, that Anthony took up at our first meeting, as though he were a pound coin both linking and separating them. Secondly, if the pound coin conferred ownership of the Double Burger, this implies that Anthony saw himself as being in a position to possess both parents orally, at the same time as preventing them from feeding each other (Klein 1957). Later in treatment, when Anthony’s phantasy objects were separating out from each other and becoming more ordinary as well as easier to tell apart, he would Downloaded by [New York University] at 03:54 14 August 2016 make the calf feed in turn from the cow’s udder (‘Yummy milk’) and from the bull’s genitals – early phantasies which are familiar from the work of Melanie Klein (1932). This shows a considerable development from the previous position in which he tried to grab my watch, ring or scarf as part of a life-or-death struggle, rather than feed from organs acknowledged as being part of someone else. As I have already suggested, this earlier stance resembled that of Tustin’s patients: David (Tustin 1972a), who tried to build up his identity by snipping powerful bits off his father; and John, who was surprised to find that ‘the red button grows on the breast’ (Tustin 1994c: 7) rather than being part of his own mouth. In children with Aspects of body image and sense of identity 105

autism, a constellation in which two people are engaged in a life-and-death rivalry for a single essential thing can often be the form in which a three-body relationship is manifest. On a part-object level, this would mean that the nipple is not experienced as a vital link between mouth and breast or bottle: instead, mouth and breast are felt to be competing for ownership of it (Rhode 1997).

The tripartite structure of ‘the Face’ When Anthony was between the parents, both joining them and separating them, it was as though he had become this link that they were supposed to fight over. The cruelty of his smile at such times was the only clue to the emotional complex- ities involved. No doubt the fact that his parents took turns putting the children to bed while the other went out for a break, and that they generally found it quicker to get Anthony off to sleep by lying down next to him, fed into his idea that he had the power to interfere in an oral intercourse between them by forming a couple with whichever parent was available. When Anthony was not between the parents, the experience of waiting appeared to take on the terrifying qualities of being physically mutilated and ignored which I have already described. It then seemed that the parental couple that was united in excluding him was linked by something between them that was not himself. The following vignette illustrates some of the properties of this ‘something’. Instead of being an emotional link between the parents, it appeared to be a physical join (the glue that he used to stick a cloth ‘plaster’ to the wall). At the same time, it dislodged Anthony from his preferred position between the parents, as though it were a rival child. Finally, when at the end of the play sequence Anthony ate the glue, this seemed an example of the confusion between food and babies, and illustrates how feeding could be less a matter of taking in nourishment than of separating and damaging an impervious mother-baby-father threesome.

When I came to the waiting-room to fetch him, Anthony responded by jumping at me suddenly, growling in the Giant’s menacing voice. Once we arrived in the therapy room, he quoted from a story about Thomas the Tank Engine who disobeyed the Fat Controller (both characters in a series of well-known children’s stories and television programmes). Thomas fell down a mine

Downloaded by [New York University] at 03:54 14 August 2016 from where he had to be rescued. Anthony seemed to feel that taking over a father figure’s powerful voice in order to break through a boundary (the inter- val between sessions) meant literally falling into an abyss inside the mother or the therapy room. (Rhode 1998: published in German) He then noticed three indentations on the wall, arranged as though they were two eyes with a mouth below them. He traced round them with his finger to make the outline of a face, saying, ‘Poor eye, poor eye’ (‘poor “I”’). He made a sticking plaster for the eye from a strip of J-cloth, and stuck it to the wall with glue from a solid glue-stick to cover the indentation. One end of the strip 106 Maria Rhode

curved away from the wall like a label. Anthony tugged at it, as though testing whether he could pull it off; then tugged at the tongue of his shoe, and with his teeth at bits of loose skin on his fingers. Next, he pushed the stick of glue upwards so that it protruded from its case, and pinched off little bits to eat. When I removed the J-cloth ‘plaster’ from the wall in preparation for the end of the session, Anthony rolled the glue remaining on the wall into little balls resembling nasal mucus and ate them. He then picked bits of mucus out of his nose and ate these as well. (Rhode 1998: unpublished in English)

Anthony seemed to think that the holes in a face – the eyes and mouth – were signs of the damage that is caused when the child bangs into a ‘brick wall’ object (the ‘cruel mummy’) that is taking no notice of him. He appeared to equate them with the mine down which Thomas the Tank Engine had fallen when he disobeyed the Fat Controller. It was as though the wait between sessions had been imposed by the prohibition of a controlling father figure. Anthony’s sudden aggressive jump in my direction, presumably in defiance of this prohibition, served the purpose of making me take notice of him – in his terms, it made eyes in the Face. (Indeed, both at home and at school Anthony had got into the habit of getting himself noticed by being naughty). However, being noticed seemed to go hand-in-hand with damaging me as a mother-figure, so that he ‘fell down the mine’ into me and needed rescuing. ‘Mending’ the damage in the wall by restoring its tripartite structure (using glue to stick the J-cloth skin over the hole-eyes) makes the eyes blind again: the child seems to face the dilemma of choosing between a blind object and a broken one. Eating the mucus-like glue seemed to be a matter of ingesting the substance that should have bound together two essential parts of the Face. One could imagine a nursing baby looking into its mother’s face and blaming its own feeding for any sadness or withdrawal to be discerned there (Meltzer et al. 1975). Later in treatment, Anthony did in fact manage a better solution: instead of sticking J-cloth over the eye ‘holes’, he turned them into seeing eyes that no longer looked broken by adding a coloured pupil with a felt-tipped pen. It is interesting to note similarities with material from a patient with encapsulated autistic features described by S. Klein (1980). This woman spoke of her Downloaded by [New York University] at 03:54 14 August 2016 feelings of insecurity in terms of a structure of bricks collapsing: ‘… it became apparent that this was due to her attacking the cement which bound her together, namely [the analyst’s] interpretations. Her own association of cement with semen showed her hostility to the creativity of both parents, who were not allowed to come together in her mind.’ This same patient had ‘a dream in which she had two swellings on either side of her body to which she associated sitting between two pregnant women at a dinner party’; this was linked with ‘omnipotent appropriation … of her mother’s genital and breast creativity’. Some of the basic patterns in Anthony’s material (attacks on glue or cement; being between two people) appear very similar to this. However, his picture of the parents is at this Aspects of body image and sense of identity 107

stage far less differentiated. In the adult woman’s material, paternal and maternal creativity are represented in different trains of thought, and sitting between two people leads to taking over the qualities of the parent of the same sex rather than to forming a threesome with a couple that is physically joined together.

The body image and the image of the object The integrity of Anthony’s own skin seemed to depend on the integrity of his object’s skin: he plucked at his cuticles and tugged at the tongue of his shoe in just the same way as he tugged at the protruding J-cloth ‘skin’ of the Face. Similarly, he appeared to equate his own balls of nasal mucus with the balls of glue, whether these were pinched off the glue-stick or extracted from the Face after the J-cloth-plaster-skin had been peeled off. The pun of ‘poor eye’ and ‘poor I’ highlights this equation of self and object. Two different processes seem to be involved here. Firstly, there is the process which Bick (1968, 1986) and Meltzer (1975) have called adhesive identification, and Tustin (1994c) has termed adhesive equation with the aim of emphasising the complete identity between self and object and the lack of any acknowledged space between them. This equation takes place on the basis of surface qualities, so that in the absence of the object the child collapses. The second process is that which Winnicott (1967) has called mirroring: he proposes that the baby derives its fundamental sense of existence and goodness from what it sees reflected in its mother’s face. I shall return to these issues later.

Cannibalising babies: devouring and being devoured Anthony’s dilemma, vis-à-vis the Face, of having to choose between a blind object and a broken one was a fair representation of the drawbacks involved in his strategy of getting attention by attacking his siblings or children at school. It was as though he blamed them for whatever distress he experienced: if he were not between the parents forming a threesome with them, then the other children must be in that position, transforming a parental couple into the kind of combined object I have described. While he could generally count on getting attention by Downloaded by [New York University] at 03:54 14 August 2016 attacking another child, the quality of this attention was of course hostile. It is as though attacking the baby that was felt to be joining the parental couple and forming a tripartite structure that excluded him damaged the link between the parental couple, who then came together to attack him. In Bion’s terms, ‘links … being impregnated now with cruelty, link objects together cruelly’ (Bion 1957). The confusion between food and the link between the couple (the balls of glue which Anthony ate) implies a model in which eating damages the couple by extracting the link between them, which appears to be experienced as a very primitive version of a ‘baby’ that participates in the parents’ relationship. Eating and growing becomes confused with separating a parental couple which belongs 108 Maria Rhode

together (Rhode 2000). By implication, the child who has done this makes himself vulnerable to being devoured by the parents when they come back together, as though they formed a giant, vengeful mouth cruelly snapping shut. Indeed, Anthony enacted chilling scenes of mutual cannibalism between the generations. Baby lambs cannibalised adult sheep (‘sheep bleeding’, as he said) and were in turn cannibalised by the adults. This felt like an eternal, unbreakable vicious circle. Nothing was resolved: the protagonists merely exchanged roles. Anthony would appear as aggressor or victim depending on which physical space he occupied. In the therapy room, he growled in the voice of the devouring Giant; in the stairwell, he pleaded not to be devoured.

‘Eating the grass’: horse, grass and shadow As a counterpoint to these sequences, Anthony presented what seemed at first to be a more benign alternative. Tipping the horse, cow or bull forward so that it was balanced on its muzzle on the table, he would say, ‘Eating the grass’. This looked like quite a realistic representation of a cow or a horse cropping grass in a field and felt like a welcome contrast to the gruesome scenes of cannibalism between the generations. However, it struck me that the position of the grazing animals was the same as that of the cow that Anthony had balanced on its muzzle on the mirror, forming the mirror-image that he had described as ‘Mummy and Daddy’. I then noticed that he seemed to be looking fixedly ‘into’ the table rather than at its surface or at the horse, cow or bull balanced on it. Following his glance, I saw the shadow which the animal cast on the table and which was usually so faint that I might well have overlooked it except for Anthony’s fixed concentration. What had appeared to be a representation of a herbivore harmlessly grazing therefore took on a more problematic quality. If one thinks of the grass – the ‘in between’ element in this tripartite structure of animal, grass and shadow – as occupying a position analogous to that of the glue-link in the Face’s tripartite structure of wall–glue–J-cloth, then the implication follows that the horse is nourishing itself by eating the grass at the expense of its own shadow, which becomes a starved, damaged and potentially vengeful object. This suggests a mutual antagonism between two objects that are not identical – Downloaded by [New York University] at 03:54 14 August 2016 whether between a mother and father who are not mirror images of each other, between the generations or between different aspects of Anthony’s own personality. Taken on that level, the material calls to mind Bion’s imaginary twin (Bion 1950) or the identification in Ancient Egyptian ritual of one twin with life and light and the other with the underworld and darkness (E. Rhode 1994). Barrows (1999), whose bulimic patient with significant autistic features described herself as a shadow person, linked this to an identification with her parents’ dead siblings whom they had been unable to mourn. Anthony’s father in fact suffered major bereavements, although I do not know enough details to be able to suggest a meaningful link. Aspects of body image and sense of identity 109

Discussion Anthony’s anticipation of trouble from the horse’s shadow is an example of the seeming impossibility of achieving what Bion (1962a) called a commensal relationship, in which two objects share a third to the benefit of all three. Instead, his world was one in which life-or-death struggles for powerful bodily ‘bits’ (Tustin) led to an eternal see-saw, in which there seemed no alternative to being either a completely helpless victim or a cruel and implacable victimiser. In this world, the experience of links was highly aberrant. The nipple did not seem to be a vital link between Anthony and the breast or bottle, but something to be fought over like the grass between horse and shadow. Similarly, the link between the parental couple was experienced as the cruel cause for the mother- figure’s imperviousness to his distress. This area has been explored by Britton (1998), who proposed that a baby with a mother-figure who is incapable of reverie and alpha-function may continue to cling to her for the sake of survival while blaming the third party of the Oedipal triangle for the blocking of non-verbal communication. For such a baby, the closure of the Oedipal triangle – the recognition of the link between the parents – is experienced as a disaster. To this formulation I would add that another child, as well as a father-figure, may be blamed for the blocking of non-verbal communication, and also that this area of experience presents scope for confusions between a mother-figure’s mental imperviousness or preoccupation, and her physical occupation by a rival (Wittenberg, 1975; Rhode, 1999). These confusions seem to me to be in large part responsible for the aberrant way in which children with autism experience their own bodies. This leads me on to the way in which Anthony equated his own skin with the skin of the Face. As I have suggested, two processes seem to be involved: adhesive identification (Bick 1968, 1986; Meltzer 1975) or adhesive equation (Tustin 1994c) and the process of mirroring (Winnicott 1967), in which the baby sees himself reflected in his mother’s glance. Although a fuller discussion goes beyond the scope of the present chapter, I would suggest that the instances of adhesive equation in the Face material, in which Anthony seemed to experience his skin as being identical to the Face’s skin rather than like it, may be to do with his feeling that the Face was blind to his individuality. This problem would be compounded by the

Downloaded by [New York University] at 03:54 14 August 2016 seeming impossibility of getting himself noticed – of creating seeing eyes – without damage to the object. This links with the importance for the child’s development of being seen as himself (as he must be if the mother’s vital capacity for alpha- function is not to be interfered with) rather than as the representative of figures from the parents’ internal world. This line of enquiry was opened up in Fraiberg’s seminal paper (Fraiberg et al. 1975) and has particular relevance to autistic spectrum disorder (Tischler 1979; Earnshaw 1994; Tustin 1994c; Barrows 1999; Klauber 1999; Reid and Alvarez 1999; Rhode 2000). It would make sense that a child who did not feel mirrored in a way that validates his own individual identity should fall back on adhesive mechanisms leading to a sense of being identical to his object. 110 Maria Rhode

Freud described equations between self and object as occurring in unresolved mourning (Freud 1917) and in certain perversions (Freud 1919). Rey (1986) observed a similar lack of differentiation in psychotic patients whose search for a cure turned out to be the search for someone who could cure their damaged objects. In Anthony’s case, adhesive equation with an object which he perceived as damaged led to the perpetuation of his anxieties concerning his bodily integrity. It also made it possible for him to exert delusional, magical control over his object by means of manoeuvres with his own body, since this was felt to be identical to his object’s body. For example, when he was frightened of falling down a crack between desk and chair, he might try to deal with this by clamping his lips tight together: as though making sure that no crack opened up between his own lips would ensure that no crack down which he might fall could open up between desk and chair. On a few occasions when Anthony did feel recognised, he enacted a benign feeding experience in stark contrast to the scenarios I have described. Equally, he sometimes genuinely felt that there were enough resources for three people. When this happened, his cruelty in the therapy room diminished and he did not appear to feel in danger of being devoured in the stairwell. Otherwise, he seemed to cope with the dilemma of devouring or being devoured by not maintaining a stable identity of his own. Instead, his identity shifted rapidly through the three aspects of the horse-grass-shadow. None of these positions was satisfactory or even safe. The horse (the dominant, cruel part of Anthony’s personality, which allowed no scope to his softer side and was primarily expressed in the therapy room) was constantly on guard against the shadow. The shadow (I saw this as Anthony’s softer side, which he seemed to feel threatened by and which suddenly overtook him in the stairwell) seemed to be allowed no proper existence of its own. The grass – the ‘in between’ element – got eaten: even being between the parents, since this was done with the aim of separating them, left Anthony vulnerable to being obliterated by two parts of a vengeful ‘mouth’ snapping shut. Indeed, any configuration that resembled the two parts of a mouth appeared to be highly dangerous. When Anthony was falling off the desk, he seemed to feel safer, however unrealistically, if he could hold onto the stretched-out drawstring of his tracksuit bottoms. However, when he doubled the string back on itself, it Downloaded by [New York University] at 03:54 14 August 2016 immediately became threatening: he slid his hand between the two strands, and they appeared to ‘bite’ it off at the wrist. A sense of safety, however delusional, seemed to flow only from the undifferentiated continuity of an umbilical-cord-like string (Winnicott 1960c), or from a tripartite structure in which the baby was felt to be the link between the parents and to participate in their relationship. In time, Anthony may come to develop more confidence in the possibility of dealing with the ordinary oral aggression of ordinary mouths. In several sessions I have had to rescue farm animals from being devoured by implacable lions, in order, as I said earlier, not to collude with what felt like the ethos of the concentration camps, and on each such occasion he has commented at the end of the Aspects of body image and sense of identity 111

session, ‘animals better’. Mostly, however, this issue still appears as larger than life and too frightening to tackle directly. To summarise, for Anthony, the experience of separateness carried with it existential terrors. It also carried with it extreme fears about being dismembered and eaten, and about the effect on his object of his oral aggression which was easily confused with self-assertion. He attempted to circumvent these dangers – represented by a snapping mouth-like double structure which felt like separated parents reuniting vengefully against him – by means of various coping devices. He might behave like a mutually adoring parental couple that excluded me; he might assert that he formed a threesome with the parents, indeed that he was the link between them; or he might clutch onto the drawstring of his tracksuit bottoms as though it offered the uninterrupted continuity of an umbilical cord that could protect him from a catastrophic psychological birth. Ringing the changes in terms of which aspect of the threesome of horse, shadow and grass he was being at any given moment meant that his sense of identity remained highly unstable.

The relevance to patients with eating disorders Patients with eating disorders can sometimes resort to some of these same self- protective strategies, although individuals vary in terms of which position of the tripartite structure of horse, shadow and grass they predominantly occupy. They may also vary in terms of whether they think of themselves as being ‘between the parents’ or whether they use food as though it were Anthony’s ‘umbilical’ drawstring, that is in order to ward off the experience of separateness. For example, a young woman came to treatment some years after suffering from quite severe anorexia during the time when her parents, who were separated, had been going through crises in their new relationships. She felt that she had been conceived in order to cement her parents’ marriage and that her mother had been depressed during her early childhood. This patient’s ambition was to fit into clothes that she had worn before reaching sexual maturity. If we take seriously her idea of being the cement that bound her parents together (in terms of Anthony’s scheme, the ‘glue’ that held together the two components of the Face), then eliminating herself could be thought of as expressing both her wish to unite them and her wish to separate them. Occupying more space would necessarily Downloaded by [New York University] at 03:54 14 August 2016 force her parents apart, particularly if the space she occupied were that of a sexually mature woman. On the other hand, eliminating herself as the cement or glue would cause the marriage to fall apart. Joyce McDougall’s formerly anorexic patient Georgette, as I have mentioned, felt that she shared in the analyst’s life to the extent of referring to ‘our’ husband. McDougall (1989) suggested that Georgette behaved as though there were only one husband between her and her mother/analyst. She seems to have experienced herself as part of a threesome in which she and the analyst were two burgers ‘sharing’ a pound coin, or a horse and shadow ‘sharing’ the grass more equitably than Anthony seemed to think was possible – an arrangement which allowed her 112 Maria Rhode

to circumvent in the transference the highly problematic relationship she had had with her mother. This delusional world view was resolved with the working through of Georgette’s sense of oral Oedipal deprivation; before this, she had completely blanked out the existence of a sexual parental couple, although she had managed to get married herself and to train as a doctor. An anorexic 15-year-old girl whom I have described elsewhere (Rhode 1979) shared Georgette’s apparent phantasy of there being only one life between two people – or indeed one of anything desirable. This girl, like Anthony, confused food with rival babies which were felt to leave no room for her inside a mother- figure. Birth for her meant being literally cut out of a ‘matrix’. In reality, her mother had been concerned about the effect of another child on her marriage and had seriously considered a very late abortion; this was to be the fate of a number of later pregnancies. For a long time this girl had an ‘unborn’ quality, as though she kept herself in the position of the shadow. She seemed to feel that safety lay in repudiating sensuality and desire – ‘Gold kills’, she said, ‘because everybody wants it.’ In a similar vein, both Sheila MacLeod (1981) and the anorexic patient described by Rey (1994) seemed to turn away from food in order to exercise some degree of control over what felt to them like a destructive relationship with the mother or with both parents. This links with Williams’ (1997) description of the use of the infant as a ‘receptacle’ for maternal projections and her proposal that a ‘no-entry defence’ can be a means of keeping these out. Such projections would include the transgenerational factors first outlined by Fraiberg et al. (1975). As I have already mentioned, MacLeod needed to be pregnant – to contain an actual baby – in order to feel that she could expand above the eight-stone mark. This invites the speculation that she may have needed proof of being able to expand without damaging a baby, as though she and a baby were horse and shadow. It may also be that the condition of pregnancy felt similar to Anthony’s position ‘between the parents’ and thus allowed any possible fears of mutual destructiveness (cannibalism) between the generations to be circumvented. Fears of this kind were also central to Tustin’s treatment of a 13-year-old severely anorexic girl, who gained weight when the transference relationship was experienced as ‘good’, involving endless mutual gratification (much as in Anthony’s picture of a mutually adoring parental couple). This girl lost weight Downloaded by [New York University] at 03:54 14 August 2016 when the experience of frustration or limits led to a ‘bad’ relationship in which patient and therapist lived at each other’s expense. Deprivation, says Tustin, ‘led to the phantasy of biting her way greedily into my body to take out the desirable supplies I had there’: ‘To decide to grow and to live meant draining her mother’s resources’ (Tustin 1986). Rey’s patient, for whom mother and baby were similarly locked in a mutually destructive relationship, seemed to feel it impossible to disentangle them by ordinary means and was tormented by the lack of a sense of her own identity (Rey 1994). She resorted to the drastic device of starving ‘herself’, which was supposed to kill the mother and free the baby. This again could be thought of as Aspects of body image and sense of identity 113

though the mother were the horse and the baby were the shadow. In Barrows’ bulimic patient (Barrows 1999), on the other hand, the sense of being a ‘shadow person’ seemed at the beginning of treatment to embrace the whole of her personality, until the possibility of inhabiting the world of other human beings emerged during treatment. Finally, I wish to mention a middle-aged woman who was obese rather than anorexic, and who had in the past suffered from alcohol abuse. This woman shared with my 19-year-old former anorexic patient the fear that she had caused her parents’ marriage to break up by reaching puberty. She had had little experience of a supportive parental couple: her father had been in the army so that she did not know him until she was nearly one, after which she felt that he intruded violently between her mother and her. Like the father of Barrows’ patient, this father had suffered unmourned, traumatic bereavements. His means of asserting mastery over the threat of death seemed to be to insist on numerous abortions, with which his wife colluded. My patient, who as a young woman had attempted suicide when her mother told her about these abortions, had vivid memories of feeling lost in a terrifying blackness when her parents had left her in a residential nursery as a child. She attempted, not very successfully, to fend off the repetition of such experiences by means of relationships in which her partner was supposed to be always available, as though they formed a version of Anthony’s ‘Mummy-and-Daddy’ mirror-image. Her overeating and alcohol abuse could be seen as ways of denying separation – something like Anthony’s umbilical cord. At the same time, she was equating herself with her father by being overweight, and with her mother (who drank heavily when her husband left her) by means of her alcohol abuse. This calls to mind Anthony’s equation of his skin to the skin of the Face.

Concluding remarks I have attempted to illustrate similarities in the body image and sense of identity between a boy with autism who experienced eating as a highly destructive and dangerous function, and female patients with eating disorders. In each case, major difficulties (whether caused by maternal depression, transgenerational issues or other factors) appear to have interfered with maternal mirroring of the baby’s Downloaded by [New York University] at 03:54 14 August 2016 identity. In Tustin’s terms (1981), psychological birth was experienced as psychological catastrophe: being a separate individual was experienced as highly dangerous, either to the person themselves or to the parental couple and other children. Bodily integrity felt under threat, and the sense of identity appeared unstable or confused. While my obese patient used food and alcohol to deny separateness, anorexic patients appeared instead to deny any bodily needs. Since food often seemed to be confused with rival babies who occupied the mother figure, taking in food could be misconstrued as being pushed out of forming a threesome with the parental couple. Anorexic patients’ fears that eating would make them unattractive may 114 Maria Rhode

be to do with feeling pushed out of the parents’ sexual union into a state of bodily fragmentation and extreme vulnerability. Young (1996) has reported a similar reaction to the mental ‘food’ of the analyst’s words, which had to be fended off as they painfully exposed a ‘defective (wounded) surface’. In conclusion, it is obvious that crucial individual differences in these patients remain to be explored. Differing attitudes towards sensuous experience – which from Tustin and Meltzer onwards has been described as often serving anti-developmental purposes in children with autism – are likely to be crucial. So too is the proportion of the personality that is free to function outside the realms I have been concerned with here (Bion 1957), and, within these realms, the degree of stability or rigidity in the adoption of any one coping strategy (Rustin 1997). It is my hope that thinking about Anthony’s extreme predicament may be useful in understanding similar constellations in some adults with eating disorders. Downloaded by [New York University] at 03:54 14 August 2016 Chapter 8 Long-term mother-child psychotherapy Infantile autism with cerebellar anomaly1

Bianca Lechevalier-Haïm

It is quite rare to come across cases of infantile autism in which cerebellar abnormalities are discovered and are treated by analytical psychotherapy from very early on in life for a sufficient length of time for considerable improvements to be achieved. Such cases pose the question of etiology. A multi-factorial approach seems to be required in these cases, putting aside any polemic concerning psychogenic as opposed to organogenic etiology. In this chapter, I do not pretend to enter into an exhaustive scientific study. In the aftermath of Martine’s treatment, a whole new working-through of hypotheses concerning the interplay of dynamics in this mother-daughter psychotherapy had to be made, taking into account both the neuro-developmental organic anomalies and the problem situation involving mourning that presided over this girl’s birth. In my view, the question is still open as regards the impact of congenital lesions per se and the functional aspects of development that may subsequently have modified the brain tissue. According to Squire and Kandel (1999), all experiences (and all traces of these) physically shape the brain before it reaches full maturity, and perhaps even afterwards too. They argue that long-term memory requires the synthesis of new proteins that stimulate the neuronal growth factors, which play a role in forming new targeted networks. The cerebellum has long been thought to have a direct impact on the genesis of infantile autism. For the past ten years or so, researchers have used brain imagery to highlight brain and cerebellar anomalies in children with autism. Downloaded by [New York University] at 03:54 14 August 2016 Some investigations were comparative studies that included a sample of non-autistic children. Courchesne et al. (1988) showed that the surface of lobules VI and VII of the vermis cerebelli was significantly smaller in a group of 18 autistic persons who did not present any associated neurological syndrome. In 1994, the same research team showed that vermis hypoplasia is associated with a reduction in volume of the cerebellar hemispheres. Neurophysiological proto- cols have highlighted, in children with autism, disorders of sensory modulation and a specific topography of responses. Other studies have reached similar conclusions and the discovery of cerebellar anomalies in children with autism has given rise to interpretative hypotheses. 116 Bianca Lechevalier-Haïm

The role played by the cerebellum is not restricted to what has long been known as regards motor function; it encompasses cognitive tasks, in particular language and selective attention. Garreau (1997; Garreau et al. 1998) has shown the important and specific influence of the cerebellum on balanced gestural production. From a ‘dynamic development’ point of view, he suggests that any initial disturbance in the development of a structure like the cerebellum may result in the malfunctioning of other structures or developmental systems that appear later. Tests of object permanence would seem to indicate that children with autism do not have the capacity for simultaneous integration of two stimuli involving different sensory channels. Garreau suggests that one or several genetic anomalies could be among the endogenous causes of this neuro-developmental disorder. As to exogenous factors, he indicates that some infection or other at a particular moment in the development of the central nervous system could well interfere with this process. In the past five years, many papers have been published concerning the role played by cerebellar pathology in cases of autism. The resultant developmental dysregulation in certain cortical (including temporal) areas has an effect on cognitive development, especially with regard to language. These disorders lend weight to the hypothesis that there are in autism faults in the complex connections between the neocerebellum and certain cerebral zones. According to Fatemi et al. (2001) cerebellar atrophy would appear to be the consequence of an anomaly in cell migration due to a reduction in the regulatory factors of the apoptosis: Bcl-2 and Reelin. I do not want to engage here in a discussion about etiology, but rather to leave open these questions concerning dynamic modifications in the psyche-soma as evidenced in one particular case. This patient was treated from age three months and, in the analytical space, the therapy had a lot to do with the relationship between mother and daughter; this was a long-term therapy with two sessions per week, and it enabled the patient’s father to find his place too. The question that can be asked is: did the analysis modify not only the structure of Martine’s internal world but also her neuro-motor development? Given her hypotonia, her difficulty in keeping her balance, her constant falling down, etc., what kind of reciprocal cathexes were established between her and the adults in her immediate circle? What would have been the result if another kind of Downloaded by [New York University] at 03:54 14 August 2016 treatment had been carried out, one that focused on the ‘handicap’ and its ‘re-education’, paying little or no attention to awareness of annihilation anxiety? And if the child had had strictly individual therapy, what kind of sense of identity would she have processed in the face of such devitalizing projections? If the parents had not been so directly and mindfully engaged in the treatment, the basic assumption of a genetic anomaly would have done nothing to help the intergen- erational cycle of projection and introjection. In the light of our present knowledge, a polyfactorial origin of infantile autism is an acceptable hypothesis, in the same way that, when this condition improves, the favorable outcome is no doubt due to the interplay between several factors. Long-term mother-child psychotherapy 117

We cannot isolate the effect of psychoanalytic treatment as such from the rest of these factors.

The grandmother in the mirror In January 1990, I would very often carry Martine in my arms and walk round, exploring the therapy room with her. We stopped in front of a mirror; she recognized her reflection and smiled at it. Her mother came up to stand beside us. Martine was eleven months old at that point. At around that time, in an analytical session with one of my adult patients who was about to give birth (and was quite apprehensive about it), I felt myself having to deal with annihilation anxiety relating to that patient’s past history. This anxiety evoked for me a vampire-like identification with her grandmother. I fell asleep during the session, then woke up suddenly in the middle of a dream in which I saw myself as a baby with a smile on my face. I wondered about the processes that had led me to evoke this narcissistic image. In my associations, I suddenly saw Martine bouncing exultantly as I held her in front of the mirror, with her mother, whom she was beginning to recognize in the reflection, standing beside us. I remembered one of my own photos, in which my grandmother is holding me up to a mirror. A twin representation of a delighted baby and a supportive grandmother figure had been mobilized by a narcissistic identification as a defense against annihilation anxiety. What could be said of this grandmotherly counter-transference in the ongoing process of recognition and differentiation? And the role of the paternal transference?

Session: 26 February 1990 Martine is feeling sad again after our separation for the short vacation break. Clinging to her mother, she explores in an autistic way the underside of her playthings. She finds a toy that represents a paternal figure. She rubs her hat against this character’s hat, then rubs it against her cheek. This is the hat she wears when she comes to her sessions with me. Then she crawls on all fours up to the mirror and looks at herself. She looks at me, then at her mother, smiles at her reflection, and tries to catch hold of her image in the mirror; she thinks for a bit and I hear Downloaded by [New York University] at 03:54 14 August 2016 her say ‘Daddy,’ then the syllables of her own name (which in reality begins with ‘Ma’). I had the feeling that when she seemed to be thinking, she was sensitive to the fact that her father was not present. She chatters a bit, her mother lifts her back onto her feet, she goes towards the curtains and, for the very first time, plays at ‘peek-a-boo’, looking me straight in the eye. In April 1990: Martine’s father is present. He is ill once more, and worried about his daughter’s sleeping problems that have again increased in intensity. Martine clings to her mother. She bites on a feeding-bottle (one of her playthings), then throws it away. Then she takes hold of her hat and bites on the strings. I wonder aloud what these strings might represent, addressing my remarks to 118 Bianca Lechevalier-Haïm

both Martine and her mother. Martine looks interested. She explores the room, with the hat strings still in her mouth. She smiles and tries to stuff the whole hat into her mouth. I say: ‘Daddy’s hat, like the strings, taking it all inside Martine so that she can have it when she leaves.’ She then moves away from us and goes round the room. I say that Daddy’s strength is helping her to let go of us. Martine says ‘Daddy.’ She goes to the mirror, recognizes her reflection, and begins looking for things that are hidden away. Her sleeping problems ceased soon after this session.

Anxiety about falling In June of that year, when she was 18 months old, she started walking – but she kept falling down heavily. It was really quite startling: she would dash forwards as if space and intervening objects just did not exist. She would stagger as though she were drunk or suffering from vertigo. That brought to my mind what Didier Houzel (1985) has written about the whirlwind universe of autistic children. She would stumble and collapse, screaming as though she were falling endlessly without any hope of finding something to hold on to. She could not get back on her feet without her mother to help her. The mother, terrified at all this, would look at me reproachfully, blaming me for having pushed Martine into that kind of adventure in space, with the risk of provoking a fatal fall. It was not until she was about five years of age that Martine managed to walk in a much more stable manner. In her sessions, she would keep on over and over again climbing onto the table or some other item of furniture then jump onto the couch on which her mother was sitting, my outstretched arms helping her to deal with the gap that separated them. I thought about what Frances Tustin had to say concerning annihilation anxiety (1981, 1986a, 1990a). I tried to make comments that, put into words, might replace my outstretched arms. Martine’s mother listened attentively, a look of astonishment on her face, but without reacting with denial. Gradually she was able to avoid anticipating her daughter’s falling down, calmed down quite a bit and indeed encouraged her daughter to move about even if there was some risk involved. Throughout the long process of facing up to the abyss of separation in this very concrete way, Martine was far ahead of her mother. Downloaded by [New York University] at 03:54 14 August 2016 November 1990: Martine is doing well. For the first time, her parents were able to take a few days’ holiday on their own. When they came back, Martine discovered how much fun merry-go-rounds could be – she flew off on a plane, waving goodbye, then came back to earth. In the session that followed, while her mother was telling me about the merry-go-round, Martine made a circular movement with her hand as I was highlighting the ‘bye-bye’ gesture she made as the merry-go-round plane was taking off, just as her Mummy and Daddy had done. Martine then drew a complete (i.e. closed) circle on the whiteboard. This was a move from polysensoriality to the polysemy of symbolization. The work of linking things together was in part accomplished thanks to the mother’s ability to Long-term mother-child psychotherapy 119

associate. The father played a very concrete role by facilitating the introjection of a link that enabled the to-and-fro movement of independence, with its implied necessity of dealing with separation. Martine is henceforth a happy and cheerful little girl; she laughs at her reflection in the mirror and, imitating her elder sister, dances around. Between sessions, however, she still experiences considerable anxiety, calling on her father to comfort her.

Expressing projections and pain Later, Martine’s parents would be worried by her continuing to fall down while she was walking; this lasted several years. They began to question the effective- ness of the psychotherapy. Neurological and radiological tests, including scans, were carried out on several occasions – the results were perfectly normal in each case. The parents were afraid of a fatal brain tumor that might have gone unno- ticed. I felt I was being accused of not taking seriously enough the possibility that Martine was in mortal danger; this accusation was repeated several times, like a leitmotiv. At the same time as this was going on, the father was suffering from precordial pain – he had a serious coronary ailment. ‘We discovered it just in time,’ was their way of putting it. In one session, I spoke of their feelings of guilt at failing to have his mother’s state of health properly examined; she died suddenly while Mme J. was pregnant with Martine. Perhaps this was a factor in their fear that Martine might suddenly be in mortal danger. (Their guilt feelings were projected into me, guilt over giving life to the detriment of the previous generation, and probably linked in the mother to the idea of an Oedipal triumph.) The father seemed to be identified in a melancholic manner with his own mother. He said: ‘It’s because of her, Martine, that I fell ill. I was worried about her, she was too demanding for me.’ I pointed out to him that he had supported his family well, not least in concrete terms because, thanks to him, his wife was able to work less in spite of their financial difficulties. But the support he gave them was not simply material, because he was also very helpful towards his wife when she was extremely depressed. Also, he could not come to the sessions very regularly, so perhaps he was feeling excluded and unsupported himself. Mr J. was then able, for the first time, to express the pain he felt at his mother’s death. Downloaded by [New York University] at 03:54 14 August 2016 Shortly after this episode, Martine was three years old. In one session, she wanted to explore her mother’s breasts. Her mother said she couldn’t do that. Martine then dropped from the couch onto a little toy chick that was a favourite plaything of hers almost from our very first meeting together. The chick let out a squeal that sounded something like a moan. Martine then began to squeal also, in a perfect imitation of the sounds she used to utter as a baby at the end of each session when it was time for us to separate. She squealed, letting herself fall to the floor and rubbing her eyes. Mme J. and I discussed what Martine might have understood about her past history. I made a remark to Martine about the pain she was feeling and the 120 Bianca Lechevalier-Haïm

impression she had of falling – the one she had now, as well as those she had when she was a little baby and I was making her leave at the end of the sessions, and perhaps also when she was an even littler baby and couldn’t drink Mummy’s milk or see Mummy’s eyes, because Daddy had taken her with him in the shop. And so maybe Martine didn’t want to look at anybody either. Martine then did the same play with the chick, and later she would make considerable use of it in this way at the end of the sessions.

Progress is slow Martine’s hypotonia gradually receded, but she still had trouble keeping her balance; she struggled against this through her ‘stunt-man’ antics, leaping from the table (with my help) to her mother’s arms as she sat on the couch. The abysses she jumped over became wider and wider. Her strabismus disappeared almost entirely, but she did have to wear glasses. She could walk properly at age four, but we were all still very worried by the fact that she was making no progress as far as speech was concerned. She spoke only a few words, and even then in a very strange, guttural tone of voice – she has, however, a highly developed understanding of language. Her anxiety seems to be interfering with the actual uttering of words, as though they were being experienced both concretely (as losing something from her body) and emotionally as falling into an endless void. She in fact illustrated this through her play with water – the stream flowing uninterruptedly – and I interpreted this to her in those terms. At the same time, her drawing changed markedly. The whirlwind shapes gave way to merry-go-rounds, closed circles that revolve. Then snails came into the picture, with their enormous spiral-shaped shells. She agreed with my interpretation concerning the snails – Martine who was protecting the baby in danger of being dissolved in the whirlwind of change. My interpretation was addressed also to Martine’s mother, who was becoming more and more impatient at the slowness of any improvement. Attempts at representing her body appeared at the same time as she drew a horse upon whose back she sat while on the merry-go-round – pointed out to her that there is a ‘horse’ in my family name (cheval – Lechevalier). In that period too, Martine began attending infant school. The headmistress was disconcerted at first by Martine’s attacks of terror, but managed to ensure that Downloaded by [New York University] at 03:54 14 August 2016 she became integrated into her class. I was trying to remain as confident as I had been at the outset of the treatment. Her continual falling down and lack of progress in verbal communication were very worrying. At first, I had thought that by beginning therapy so early on in life, she would not have to set up any autistic defenses. This was obviously not the case. In spite of the fact that she had made good progress, it did look as though Martine was locking herself into a capsule of silence, thereby stirring up her parents’ anxiety about death. More progress was made when Martine began using the words that I was putting at her disposal. She expressed pain and terror whenever she defecated – being separated from her feces. After my interpretations on this point, she would Long-term mother-child psychotherapy 121

utter sounds in the same tone of voice and with the same facial expressions she used whenever she defecated. She then began to do the same thing at home with her mother and then moved on to singing. It was round about then that, in school, she made an earthenware hedgehog, black and blue in color; it had a lot of bristles, and its head and mouth were just beginning to peek out. Ever since, that hedgehog has remained on a shelf in my consulting room.

The little devil By now, Martine was five years old. In her sessions, she kept having sudden rises in temperature. Shortly after the period in which she was anxious about losing her feces, Martine – who up till then had been such a nice, obedient little girl, a real darling to her parents because her state of fusion made her so submissive – was to change into a little devil. At the least sign of frustration, whether in the sessions or elsewhere, she would scream her head off. Separations for vacation breaks or even at the end of each session were experienced as dramatic because of the emotional intensity and the destructive aggressiveness she expressed. I had physically to restrain her – I needed all the physical strength I could muster – in order to contain these feelings and calm her down. To all intents and purposes, the sessions became a power struggle. This was also when she started using swear words – the advantage being that we no longer had to resort to physical struggling with each other; the fight became verbal in nature. In her play, there was a big lion that roared and devoured me – thereby enabling her to stand back slightly from the intensity of her affects. The manner in which I interpreted this awakened the mother’s interest and curiosity. She could witness all this, appalled and yet relieved that she was not the only one who had to bear the brunt of such problems. She was at first reproachful towards me – she felt initially that I was too lenient, then that I was too frustrating – then she identified with me and began to talk about her childhood memories of her own mother. She could see in herself the repressed aspects, and therefore felt close to what her daughter was experiencing, and was able also to introject new maternal superego aspects. She stopped trying to anticipate instinc- tively what her daughter wished, thus enabling her to be less physical in her desire for independence. This was the period during which Martine would play Downloaded by [New York University] at 03:54 14 August 2016 out either in a direct physical way or, with the help of the doll figures, her anxiety about falling endlessly and disappearing into darkness whenever I frustrated her even slightly (she experienced this as losing a part of herself that was merged with me) or when we separated at the end of each session.

Birth of the subject Martine’s powers of speech improved considerably from about age five on. One day, she expressed the pain she felt at having to exist separately. She sat in my chair and said: ‘Me Madame Lechevalier, everything here belongs to me, the 122 Bianca Lechevalier-Haïm

food, the babies, the house.’ Then she began to cry, expressing the acute pain she felt, and let herself slide to the floor, saying: ‘I’m not Madame Lechevalier. I’d like to be.’ The first person pronoun had appeared for the first time in her vocabulary. A few weeks later, just before the summer vacation, she was in tears as she came to the session. She dropped to the floor and threw all the dolls on the floor too. She said: ‘Here too there are cemeteries. Death is sad.’ Her mother commented: ‘Just next to here there’s a masonry for funerary monuments and tombstones; each time we come here, we pass it on the way.’ Martine had made an association to her paternal grandmother’s tomb. I thought of how her past history had been characterized by death, of my own personal cemetery in my internal world that perhaps Martine had caught a glimpse of. Now that she was becoming an individual person, a self distinct from all others, awareness of death and above all of the pain of mourning was also present. From that point on, her progress was astonishing, both as far as language was concerned and as regards her capacity for symbolization with access to temporality. She was then offered speech therapy because of the great difficulty she had with the pronunciation of certain sounds. Very soon thereafter she used the dolls from her own personal drawer to set up Oedipal scenarios and express her death wish as regards the maternal object. She said that Martine had taken the house, the kitchen and her mother’s things in the playhouse. She would take care of her father. Then she became a mummy herself. Manic triumph of this sort soon gave way to the pain the little orphan girl felt. Martine was on the threshold of working through the depressive position in its Oedipal configuration; she was able to integrate ambivalence and say how sad it was to be a little girl and not be able to be a mummy right away. She added that she was often afraid that her parents might die.

‘I’m falling, I’m falling, I’m dying’ The summer vacation was uneventful, and the following September Martine entered the first grade of primary school at age six. The day school started, she refused to come into the therapy room with her mother, who asked Martine to explain to me why she was refusing. Martine asked me to explain why she was coming to see me. I tried to tell her something about her past history. Martine Downloaded by [New York University] at 03:54 14 August 2016 screamed, sobbed, lay down on the floor and said: ‘You haven’t understood a thing; I’ll explain it to you.’ She then climbed onto the small bookcase as she used to do years before, and then slid down to the floor, as though she had fallen down. She commented: ‘I come to see you because I’m falling, falling, falling and I’m dying, I’m dying and dying’s sad … I don’t want to die, I’m afraid.’ She sobbed for a long time. Her mother was deeply moved by her daughter’s pain. We remained silent. Then Mme J. said to her daughter that when Martine was in Mummy’s tummy, Mummy was terribly afraid of death, both for herself and for Martine. She added that she had been very sad because Martine’s grandmother had just died, so that both she and Daddy had been very sad. I then Long-term mother-child psychotherapy 123

mentioned the fact that when Martine was a baby she had felt she was falling, falling whenever she saw that sad look in her mother’s eyes. I felt she had been attracted to the depressive void in her mother’s eyes, drawn into a black hole of non-thinking by her mother’s dead internal object. Martine then went to the wash-hand basin to fetch some water; she drank some then gave some to us to drink too. We could then share a living breast in thought, thanks to the fact that we had been able to re-establish this link with the maternal object in the analytical space.

Individual psychotherapy with Martine: development of a capacity for symbolization In the session that immediately followed this, she said that henceforth she wanted to come alone. Mother thereafter stayed in the waiting room. From time to time, at first, Martine would go back and forth from the therapy room to the waiting room. Sometimes, but very rarely, she would ask her mother to come into the therapy room in order to show her something. Though Mme J. was anxious, she did stay in the waiting room, impatient for her daughter to return; later, she would make use of this time in order to do some shopping in town. At such times her elder daughter would often accompany Martine. This girl began thereafter to play a much more maternal role with respect to Martine, as a kind of mother substitute. Towards the end of the therapy, the younger of Martine’s two brothers would often accompany his sister to the sessions. As far as contact with her parents is concerned, I began to meet them much more frequently than at the beginning of the treatment – either the mother alone, or both parents together. In her first session alone with me, one Thursday in September 1995, Martine drew a house with a long road leading up to it; next to it was a mother figure with a baby in her tummy. There was a car on the road bringing them back from the maternity unit. The sun was shining. I commented on the long road and the car of the therapy, where Martine, still inside Mummy’s tummy, was able to find a home for herself. I added a remark about how bright everything was, with the sun shining over this birth. I associated to a happy Daddy here. On the following Monday, a little girl with breasts just about to develop and with her navel visible was standing beside the house; above it Martine wrote her Downloaded by [New York University] at 03:54 14 August 2016 first name. Then there appeared a tree with a lot of green leaves. I congratulated her on these first traces of writing that she made, a way of taking possession of her own identity. I pointed out also that she was already feeling like a mummy with breasts. And the navel showed us that the umbilical link to the mother figure was now cut. Further, the little girl was now in the therapy between a house that could embrace her like a mummy and a tree-daddy with a lot of thoughts like all the green leaves. A month after this, M and Mme J. were able to go on a long trip abroad. They chose to visit Egypt. When they came back, Martine said she was going to tell me the story of the pharaohs. She spoke of an all-powerful king, and then did 124 Bianca Lechevalier-Haïm

a drawing of the pyramid that her parents had visited. ‘He thought he could live forever inside his tomb,’ she said. ‘He had to have food, a whole lot of food in there. That was a long time ago. Pharaohs don’t exist any more.’ Martine drew herself beside the pyramid, running about and skipping with a rope without falling over. One of her feet is on the ground, the other leg is raised. She has a thick head of hair. She is drawn side-on, and we can see a big ear. A statue on its pedestal is between her and the pyramid. Next to the statue, she drew a castle and a tall obelisk. In the sky, her parents’ plane can be seen. I was astonished at the powerful way in which she managed, thanks to her body movements, to highlight the contrast between the all-powerful character, motion- less, dead-yet-living in a time of its own, the immobile statue, and the lively little girl in control of her anxiety about falling over, her thoughts as dense as the hair on a radiant feminine figure, listening intently to everything that’s going on. It is true, all the same, that Martine used only black pens to draw it (no colors). I made only a short comment on this drawing, saying that in spite of the fact that the parental couple were absent, Martine was able to imagine their trip abroad with a lot of pleasure, like the lively little girl with the skipping rope; she didn’t have to be a dead pharaoh desperately trying to keep the parental figures by her side. On 22 February 1996, Martine drew a house with enough room for several generations: grandparents, parents, herself, the younger of her brothers with his girlfriend. Martine was able to take her rightful place between the different generations of couples.

Her smile in the mirror In March 1996, we had to play at visiting a cemetery. I was to remain silent while Martine recited a prayer beside the grave of her dead grandmother. She placed the grave just in front of the mirror in the therapy room. We were to say the prayer together, not just the one or the other of us alone. Martine added: ‘And if we pray very hard, her smile will appear in the mirror.’ We prayed, and Martine exclaimed: ‘There we are, we’ve won, she smiled.’ Martine-pharaoh-living/dead, the grandmother’s grave-out-of-time, was becoming individualized as a little girl who would one day die. That enabled her to perpetuate through a smile the memory of her grandmother. My counter-transference feelings in front of the Downloaded by [New York University] at 03:54 14 August 2016 mirror again evoked for me a supportive grandmother, my own.

Towards separation and the end of the analysis: working through internal objects and depression June 1996. Martine took out a tortoise and two chicks from among her playthings. She said that the second chick was a Mme Lechevalier chick but it might also be a little baby. Both chicks ate some pancakes, then they wanted to travel on the tortoise’s shell – or rather get inside, just under the tortoise’s shell. That would be easier for traveling. Unfortunately there wasn’t enough room for them. Long-term mother-child psychotherapy 125

The shell was too small, so the chicks were not going to be able to leave. That was going to be a problem: how to say goodbye, if there were no such shell? They determined to try all the same. Martine said to me: ‘I’ll never forget you.’ She made me pretend to leave with my chick, while she remained by herself. Then she said: ‘I want to leave on the tortoise.’ The tortoise began moving, with the Martine-chick on its back. The chick fell off. Now Martine had only one possibility left – to leave on her own, without the tortoise. She imitated the painful cries of the chick, then said to me: ‘Later we’ll be together again, but you won’t recognize the chick because it will have grown up. Will you still be able to recognize me one day? I’ll remember …’ October 1996. Martine began by drawing a little girl, her Mummy and her Daddy. She commented: ‘He’s ugly, he’s all black,’ adding: ‘Do you know why?’ I asked her to think about it. She replied: ‘It’s his Mummy that made him ugly like that.’ I said: ‘His Mummy? Your grandmother, the one who died?’ Martine replied: ‘Yes, that’s right, you’ve understood.’ Then she added: ‘You mustn’t make a mistake, now. It’s his Mummy who’s dead, not my Mummy. My Mummy’s here.’ Later, Mme J. told me that Martine had had a nightmare; she woke up asking who her mother was. The one in the dream or her real-life Mummy? I’m not sure whether this nightmare in fact preceded the session or followed on from it. In the following session, Martine asked me to pretend to cut out characters that she had drawn. In the play, she was the mother and picked up the drawings – of a Mummy and her little daughter – and showed them to me. The little girl said to her mother: ‘You know, Daddy mustn’t come along because Mme Lechevalier will make fun of Daddy.’ I asked her why. Martine replied: ‘Because his Mummy made him ugly.’ I said that I didn’t understand. Martine: ‘Can’t you see? He’s wearing a dress like the grandmother, a black dress like her.’ I again said that I didn’t understand and that maybe the little girl could help me out. Martine then suggested that we change roles. She was to be me, and I would be the little girl who was accompanied this time by her Daddy. I came with the cut-out Daddy figure, and Martine made fun of it (playing as me). She laughed at the father wearing a black dress. I imitated the little girl, saying to Martine/Mme Lechevalier that I didn’t like a Daddy like that; maybe he could change his clothes? Martine agreed. She then drew another Daddy, this time wearing trousers. His hair was Downloaded by [New York University] at 03:54 14 August 2016 now brown (it had been black in the previous drawing). Then she threw the first Daddy away, ‘the ugly Daddy.’ She brought me the ‘handsome Daddy,’ saying: ‘Madame Lechevalier doesn’t think he’s handsome enough yet, she doesn’t like him.’ I asked her why. Martine: ‘Because of his hair.’ She then changed the figure’s hair color, saying: ‘We’ll put some black and some blue on. It’s a new kind of black, because there’s some blue with it.’ The blue color she used was very bright. I commented: ‘The blue of the sea like a Mummy2 being mixed into the sad black color, and it all brightens up.’ Martine then fetched the cut-out Mummy figure and made it face the Daddy. The little girl looked at the whole family. 126 Bianca Lechevalier-Haïm

In the following session, Martine told me about her aunt’s birthday when she was dressed in pink. There was a party, and all the generations in the family were present: her brother, her sister-in-law, and the parents – next door to a cemetery where they all went to lay flowers. Martine added: ‘After that, we had a party, but in the evening I couldn’t dance like my parents did. I went to bed all alone in the campsite. Only adults dance.’ According to Martine, she’ll be able to dance once she’s grown up. In this psychodrama play, the objects of Martine’s inner world were being called on to the stage, as modified by the psychoanalytic encounter. She was illustrating how the identificatory bond between the father and his dead mother was transformed, in the seductive relationship with me, into a link with a living ‘blue sea/mother.’ The brightness was in the emotional complexity of this new black color in which some blueness is integrated. Martine’s mother could thereupon look lovingly at her husband, a look that Martine could contemplate; this in turn enabled her to enter into latency and go to bed on her own while the parental couple was dancing. This transformation staged by Martine corresponded to something other than a simple transformation of the objects in her internal world; there was also a transformation of the links within the space of family relationships, one that developed gradually in the analytical space. Martine was in some ways aware of this. She expressed it through her play in the sessions in which we discussed the date at which we would end the therapy – 12 January 1998, shortly before her ninth birthday. We were to pretend-play the treatment of the two little girls that we once had been, two little girls ‘who had lost their parents’ and had to consult someone. Martine was by turns the child and the consultant explaining to the little girl her past history. At the end of 1997, as we were fixing the date of the final session, Martine told me that she was going to eat henceforth in the school dining hall, grow up, and change schools: ‘That’s life,’ adding that children need their parents. At the beginning of January 1998, we danced together, swirling, swirling with our ‘handsome Daddy.’ But he was in danger of dying because of ‘his heart,’ and the Mummy had disappeared. In the end, Martine’s father is saved from dying and her mother is found once again. The daughter then goes to bed, leaving the parents together. She added that there was a difference in our two treatments. Martine said: ‘For you, with your psychotherapy, you found your parents again, but for me it was different, I had to change mine.’ I wondered what kind of rediscovery with my internal Downloaded by [New York University] at 03:54 14 August 2016 parents Martine was thinking of. Through my own personal analysis perhaps, or in the work we did together during which the little girl inside me had identified with Martine rediscovering a ‘handsome Daddy’? By giving life back to the living/dead Martine, I had given life back also to the father, danced with him and enabled him to return to the mother figure. And in that way, Martine was able to leave with her parents.

Aftermath Thereafter, I saw Martine once every three months until June 2000. She was then getting ready to attend classes in the first year of secondary school in a private Long-term mother-child psychotherapy 127

establishment. At that point, she was 11½ years of age, and puberty was beginning. She had had some remedial psychomotor sessions which brought her motor functions to about average. The detailed neurological assessment made in February 2000 was clinically normal. But the MRI showed an important hypoplasia of the left cerebellar hemisphere. Martine’s mother was very upset at this news, which called into question the somatic well-being of her daughter and gave her the idea that she had transmitted some abnormality or other to her. The father took things much more calmly. They both felt it was better not to have known about this before, because they were able to trust their daughter’s ability to develop as a whole through therapy, helping them to get in close touch with their emotionality. Martine preferred to talk to me about her puberty and about her plans for the future, including her desire to work in the artistic field. She told me that the younger of her two brothers had had a little girl, a niece for Martine, and spoke of the pain she felt when she learned that the older brother was homosexual. ‘So he doesn’t love me as a woman! He’ll never know the pleasure of having children!’ She wept. As to Martine’s abstract thinking, I should mention a session that took place in June 1997, when she was eight years old. She was telling me about how her school was going to celebrate the 14 July. The pupils had been told about the Republic. She divided a sheet of paper into four quarters. In the upper left one, she wrote ‘La Marseillaise’, in the bottom left she drew a girl with long hair – Marianne (the symbol of the French Republic, but also a close resemblance to Martine’s real first name and surname). I asked her if that was the Republic. She exclaimed: ‘You haven’t understood a thing! It’s a statue that represents the Republic.’ The symbol of the Republic is the flag, which she drew in the bottom right-hand quarter. And above that she added a couple dancing – that was how she saw the celebration of the Republic.

June 2002 At their request, I met Martine and her parents in my private consultation. Martine was very moved, she contained her emotions and gave me a big smile. She is a beautiful adolescent girl, and I’m surprised at how much she has Downloaded by [New York University] at 03:54 14 August 2016 changed. Her voice has remained the same, with its strange guttural quality. She is attending high school in a class with a small number of pupils. I see her alone, as she had requested. She wanted to talk to me about her ‘problems’. She had been told that in her previous school she had been considered to be ‘handicapped’. She asked me for some details concerning her personal history. She didn’t like the fact that, in our discussion, I used the term ‘baby aspects’ so much when I was talking about her: ‘I don’t want to upset you, but I’m an adolescent now.’ She went on to tell me about the conflicts she has with her mother over her wish to wear make-up, have a mobile phone and go out in the evenings. 128 Bianca Lechevalier-Haïm

She wonders if it’s normal to treat her mother ‘like a dog’ when they have these discussions. She’s annoyed with herself for not controlling herself better, especially since her father always agrees with her mother. She told me also about how frightened she was of being raped; she thinks that she got this idea from overhearing adults talking. She goes off to her room at times like those: ‘That way, I can breathe.’ She told me of her first feelings of love, not always reciprocated, and also of how much she adores babies – thanks to her little niece. As far as her school-work was concerned, everything was fine. She is top of her class in English, and would like to do something in the professional line with that. She’d like to discover the United States, and Egypt too – they fascinate her. I reminded her of her parents’ trip to Egypt and the sessions we had together following that. The only memory she has of her analysis with me is the drawing she made of the pyramid. She says she has forgotten everything else. All through our discussion she talked like a shy young lady, interrupting herself whenever anything funny came into her mind, or anything sad, or anything that made her think of ‘swear words’. I asked her why. ‘You don’t behave like that with an adult you don’t know,’ she replied. Thereafter, the parents came in and all four of us had a discussion together. Martine’s father said he was worried by her shutting herself in her room and listening to music without sharing that pleasure with him. Was it some kind of autistic withdrawal? Martine replied that she didn’t want her father to intrude on her; she wanted to preserve a private space for herself. Mother said that she was having trouble understanding this new generation of adolescents, so different from her older children. As we took leave of one another, I thought of the session in which she anticipated our getting together again by asking if I would recognize the little chick that was crying. What I do recognize in this contained, reserved adolescent is the original way in which she expresses her personal thoughts.

Discussion: cerebellar abnormality As far as the symptoms are concerned, in particular as regards Martine’s muscular tone and the problem of keeping her balance, it is difficult to decide how much of this was due to deficiency and how much to organic functional disorder.

Downloaded by [New York University] at 03:54 14 August 2016 According to recent neurophysiological data, both cerebellar abnormality and developmental and functional consequences have to be taken into account as regards their effect on brain circuitry and certain topographical areas. Primary depression with its annihilation anxiety and its sensations of falling perceived directly in the body (as Tustin describes in cases of autism) may in itself bring about hypotonia, walking disorders and falling down. The question arises also when both head and eyes turn away simultaneously to one side. Is this an active autistic withdrawal in order not to look into the mother’s eyes or some kind of malfunctioning for organic reasons? Rather than set these two hypotheses against each other in a way reminiscent of splitting psyche from soma, it would be more in tune with a developmental Long-term mother-child psychotherapy 129

perspective that gives due importance to the affects which are an integral part of the body to think in terms of a negative transactional spiral running counter to the usual complementarity. The functional disorder of organic origin is a source of anxiety, and this begins to resonate with the death-containing aspects that are projected into the infant. When there is no sufficiently reciprocal response, these projections are reinforced, thereby contributing to increasing the depression. This depression is perceived and is manifested directly through the body. The result is that normal development is hampered, thereby adding to the disorders already existing in the neuronal circuits. Motor functions are not cathected both because of the organic deficiency and because of the annihilation anxiety. The infant’s motor handicap then reinforces in the parents their feelings of confusion and anxiety over death. If psychotherapy had not in this case begun sufficiently early, irreversible damage may well have been done both as far as brain structures are concerned and for the construction of an individualized psychic space for Martine herself. In 1998, Bernard Lechevalier and I wrote a book called Le Corps et le Sens (The Body and Meaning) in which we discussed autism. A functional pathology of meaning seems in certain cases to be linked to ‘a particular modality of intersubjective relationships’. In this kind of relationship, the absence of three- dimensionality in adhesiveness (Tustin) and the dismantling of meaning (Meltzer) seem to contribute to establishing a pathological form of perceptual synthesis. In a personal communication, J. Cambier (who is a neurologist) said, with reference to simultagnosia, that such patients ‘cannot shift their attention away from the region in space where they have defined a part-object.’ This complex disorder, caused by a lesion, could perhaps nowadays be considered, at least in certain cases of autism, as being simultaneously due to a lesion and to a functional problem. Bernard Lechevalier has pointed out that patients suffering from simultagnosia are unable to recognize complex images or more than one image at the same time, because their eyes lock on to one detail or one part of the image in question. The lesions are either bilateral in the parieto-occipital cortex, or in the left temporo-occipital region. Bernard Lechevalier has suggested that the autistic person suffers from a disorder of activation of the oculo-motor zones. One of the effects of Martine’s psychotherapy was to enable her to modify her cathexes, thanks, from our very first meeting on, to the mobilization of polysen-

Downloaded by [New York University] at 03:54 14 August 2016 soriality; we know that this is defective in people with autism because of their monosensorial fixations. What might have happened had these anomalies been detected at the very beginning of her life? No adjunctive treatment would have been able to improve her development or have any better prognosis.

The dynamics of the analysis Did some transformation take place as to Martine’s internal objects, in the dynamics of the back-and-forth transference movements with their condensed and de-condensed projections, intertwining with and mobilizing the analyst’s own Unconscious and identifications? The analyst takes in transference elements 130 Bianca Lechevalier-Haïm

from both the parents and the child. Proactive intrapsychic modifications at the unconscious and preconscious levels are created in the analyst, with from time- to-time dream activity. Analysts have to let themselves go and allow themselves to be invaded by bodily sensations and emotions that provoke fantasies of action. While participating creatively in the patient’s play, the analyst has to put off all idea of acting and concentrate on deciphering the messages he or she receives, thereby encouraging others to be communicated and cathected in the analyst’s internal world. This brings about consequences in the analyst, in the analyst’s interpretations and also in everything that is represented through non-verbal communication in the patient’s play and the pleasure they both share in it. Fantasy representations can then be played out, and encourage others to be produced in both the child and her mother. I would tend to call this, not a transitional space, but a new field that has been opened up. The modified communications are perceived by the baby and her mother and are active inside them. Though there may still be repeated projections, new links are set up in resonance with the internal world of each of them; this in turn modifies the conflict modes that had become inflexible though a preferred type of relationship between them. Verbalization promotes thinking in everyone, but many messages that are communicated via the body contribute to setting up a range of fantasies in action, like dream-thoughts; within this field of fantasy action, the nature of relationships can change and become more varied. In the dynamics of the analysis, regressive movements may occur towards pregenitality or towards modes of psychic functioning that aim to struggle against depression by clinging adhesively to the object. In the counter-transference, the analyst may experience this as meaningless despair, as a derisory struggle of the life processes against those that promote the idealization of death. If in the child patient, a self can be born and built up as Subject, with his or her own individual bodily existence, with due awareness of eventual mortality and annihilation anxiety, and if it becomes possible to stand back from the projections that hampered the creation of a personal space, what can we hope for in the parents? In Martine’s case, she was stuck to a dead internal object of her father’s; this mobilized her mother’s Oedipal guilt feelings and, in both parents, a depressive Downloaded by [New York University] at 03:54 14 August 2016 state that neither had been able to work through. The analytical space enabled the mother to become aware of her depression and her guilt, and thereafter allowed her to rediscover the narcissistic pleasure and sensuality of the beginnings of life. At the beginning of the analysis, Martine had an experience of happy merging (Tustin’s ‘symbolon’), but she lost it afterwards when a paternal link was set up in the field of forces existing at that time. Martine managed to introject that link gradually, in spite of some regressions from time to time. It helped her, and me as her analyst, to work through our shared experience of furious despair, taking on board the risk of destructiveness and meaninglessness as we un-merged Long-term mother-child psychotherapy 131

(Tustin’s ‘diabolon’). The work we did in this painful ordeal, in association with Martine’s mother, whose superego seemed to change, played an essential role in the analysis. As the links in the Preconscious became stronger, putting words on the affects experienced, the capacity for representation of all of us who participated in the treatment was given form in the shape of a colored carpet with a repetitive pattern. Was this perhaps a ‘metabolon’ in Tustin’s sense? When I as analyst, in my counter-transference, could acknowledge the existence of annihilation anxiety, this was a defining moment of reciprocity and of differentiation. The inter- and intrapsychic mobility of all participants took place in the field that developed through our growing mutual awareness; the meaning of the emotions perceived in the body was expressed and enriched by the free associations each of us was able to make, and this enabled a sense of self to emerge as Subject with its own unity and heterogeneity. However, the mystery of how a human being comes to be born has to be respected, in the same way as insight must be respected when the self accedes through the pain of un-merging to symbolic thinking as described by Bion. Awareness of incompleteness and of mortality then falls on the self, who can then become integrated through acceding to temporality in the line of descent of successive generations. Pseudo-identification with a dead person from a preceding generation, treated as though she were still alive, then gave way to the eroti- cization of the body in a new-found liberty; the drawing in which Martine dances in front of pharaoh’s pyramid bears witness to this. Her parents’ plane in the sky shows that in her case breaking free of autistic confinement immediately involved the conflicts of the Oedipal configuration. As for Martine’s father, though his transference may have been intense, it was never analyzed. He made only a few appearances in the sessions. He operated essentially in a concrete way, denying his affects and setting great store by hyperactivity; this protected him from depression, but opened the path to somatization. Things did change, however, once he was able to integrate new identifications in the analytical field. These brought him closer to some aspects of his wife, who was sensitive and eager to listen to what her mind was trying to tell her. The value given the paternal link in the Oedipal transference onto the therapist may have enabled him to give up his identification with the dead mother that he projected into Martine. Downloaded by [New York University] at 03:54 14 August 2016 The transference interpretations given to Martine were understood by her mother with the sensitivity of the child part that was still very much alive inside her and awaiting a thinking container. Simultaneously, the adult part in her was able to benefit from new identifications. These may have helped her to soften her superego demands. What is beyond doubt is that the way her thinking functioned improved a great deal. Her Preconscious made many more new associations and became much more flexible in outlook. Libidinal cathexis of this way of functioning, with reciprocity and otherness being given their rightful place, enabled her to give up her wish to control and let her break free of sadomasochistic relationships. 132 Bianca Lechevalier-Haïm

What could be supposed as to the changes brought about in her Oedipal configuration and the guilt she became aware of through the metamorphoses and displacements of the characters played out on the analytical stage? This setting did in any case avoid the pitfalls of her feeling excluded from the primal scene, of a child being kidnapped, of envy. Or at least it enabled such feelings to be analyzed to some extent whenever they appeared in the analysis. There remains to be discussed how Martine organized her intrapsychic conflictuality at adolescence, with regard to the Oedipal configuration and the need to work through the depressive position once again, given the fact that she had to deal with the changes brought about by puberty. Meltzer (1992) has pointed out that when patients with autism are treated, there is always the temptation, at the point of crisis in development that is adolescence, to fall back on adhesiveness and use it as a defence. This can be done via two-dimensionality – through a pseudo-identification with an internal parental object. The lost object that the parent had been unable to integrate via a genuine introjective process seems to re-emerge. Feelings of guilt are then mobilized as Oedipal conflicts again come to the fore. Clinging to such feelings enables the adolescent to rediscover an old link with the parent who is in mourning. Adhesive pseudo- identification is used in order to defend oneself against different kinds of anxiety – on the one hand, those evoked by the Oedipal conflict, and, on the other, anxiety over separation (and the depression that accompanies it) due to all these new bodily transformations. The result of setting up these adhesive defences is the loss of the mental space required for constructing one’s self- identity. This space is necessary for working through the depressive position with sufficient differentiation between complex feelings of guilt relative to the adolescent’s own internal objects and to those of the parents. If the parents have not managed themselves to be helped to develop internally, the benefits of the child’s individual psychotherapy may well be called into question. Long-term parent-and-child therapy gives much more cause for hope that the adolescent will be able to go on developing in his or her own personal space, including facing up to the conflicts and the depression that are intrinsic to this particular period in life. Martine managed to ensure that her parents respected this personal space of hers, avoiding her father’s intrusiveness with its too-powerful Oedipal overtones. The conflicts between her and her mother had to do with Downloaded by [New York University] at 03:54 14 August 2016 rivalry and control on both sides. Some obsessional defences, a goody-two-shoes little-girl attitude, with me are indicative of repression. Infantile amnesia was set up in a surprisingly short time – though the link between us still remained, thanks to the emotion she showed when we first met. The parents are sensitive towards the mental life of their daughter; after all, in some ways, they are about to lose their youngest daughter … In conclusion, I would like to stress the importance of the re-adjustments that take place in this kind of treatment, begun very early and long-term in nature. Mobilizing the parents’ mindfulness, because of the fact that this was a joint therapy, enabled much more than simple accompanying consultations would Long-term mother-child psychotherapy 133

have done. Whenever a developmental crisis appeared, new patterns of relationship could be built up in the sessions, thereby avoiding relapses. I must also emphasize the unity of body and mind. At that point in life, memory traces are inscribed and organized in associative neuronal networks in a way that changes all the time. Psychic forces act probably on such inscriptions, so that lesions – whether genetic in origin or accidental – do not prevent new re-adjustments from taking place in the future. On the other hand, functional disorders may, by sheer repetition, give rise to the same kind of inscriptions as lesions do. There must have been something in Martine’s past history that, through the conjunction of certain events and the coming together in her unconscious of the protagonists of these, enabled her as an adolescent to deal with life and its conflicts like other adolescents of her generation – without having recourse to the inflexible programmes of ‘care for the handicapped’.

Notes 1. This chapter is a version of a paper that was awarded the 7th Annual Frances Tustin Memorial Prize. 2. Play on words – mer ‘sea’ and mère ‘mother’ are homophones. Downloaded by [New York University] at 03:54 14 August 2016 Chapter 9 Autistic phenomena in neurotic patients1

Sydney Klein

In recent years there has been an increasing awareness among analysts that behind the neurotic aspects of the patient’s personality there lies hidden a psychotic problem which needs to be dealt with to ensure real stability. This was particularly highlighted by Bion (1957) in his seminal paper on the differentiation of the psychotic from the non-psychotic part of the personality. However, I do not feel that this is still fully recognised. In the course of a periodic review of the progress of my analytic practice, and particularly of my patient’s habitual modes of communication, I became aware that certain among them 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 professional 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. There is an obvious parallel with what Winnicott (1960a) 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 of part of the self which Downloaded by [New York University] at 03:54 14 August 2016 cuts the patient off both from the rest of his personality and the analyst. This encapsulation manifests itself by a thinness or flatness of feeling accompanied by a rather desperate and tenacious clinging to the analyst as the sole source of life, accompanied by an underlying pervasive feeling of mistrust and a preoccupation with the analyst’s tone of voice or facial expression irrespective of the content of the interpretation. There is a constant expectation of hostility and a tendency to become quickly persecuted at the slightest hint of the analyst’s irrita- tion or disapproval. Consciously the analyst is idealised as an extremely powerful and omniscient figure who also occurs in this guise in the patient’s dreams. As a concomitant, the patient denies his persecutory feelings in spite of the evidence Autistic phenomena in neurotic patients 135

subsequently given by dreams and other analytic material. For example, one patient offered to raise her fees as she felt so well and I accepted her offer. The next night she dreamed of a large white vampire bat and of a baby wriggling to escape from a tube being put into its foot for a blood transfusion. It was obvious that although she had offered to raise the fees herself she experienced me as a vampire-like breast who was sucking her dry instead of filling her with life. Nevertheless her fear of me led to a firm denial of her persecutory feelings. Another feature of the analysis is the tendency to bring up some topic which the patient seizes upon with obsessional rigidity but which is never worked through because of the inability to take in interpretations and deal with the problem. There is a striking similarity with the behaviour of autistic children who play with a ball or toy in a compulsive repetitive way and who scream and resist any attempt to interfere with or change the pattern of play. Sooner or later, however, the patient’s personality structure is made clearer by references in a projected form. For example, one patient said, ‘I can never get through to my mother. She seems to have an encapsulated relationship inside herself.’ Another described an autistic child she had seen in exactly the same terms. Yet another patient described herself as drifting away from me, even though she was interested in what I was saying, in exactly the way autistic babies are described as drifting away from their mothers. As soon as I was able to draw the patients’ attention to these phenomena in themselves they began to dream about being in walled towns or fortresses, stone buildings, etc. In addition, crustaceous creatures began to appear in their dreams such as cockroaches, armadillos, lobsters, etc. (cf. Tustin 1972a). Previously these encysted parts of the self had been dealt with by projection into the body, producing various types of psychosomatic symptoms, or into other people. I would like to describe one patient in some detail to illustrate my point. This female patient had politely but consistently denied all feelings about weekend or holiday separations even though the material pointed quite clearly to feelings of exclusion from the parental couple. Just prior to the second holiday break she suddenly developed acute abdominal pain and was rushed to hospital for removal of what turned out to be an inflamed ovarian cyst. Prior to the next analytic break she developed an acute swelling in her breast which was operated Downloaded by [New York University] at 03:54 14 August 2016 on and diagnosed as acute cystic inflammation. However, despite the operation she continued to complain of pain and swelling in both breasts. Subsequent sessions indicated that the swellings were equated with omnipotent appropriation by projective and introjective identification of her mother’s genital and breast creativity. This was shown by a dream in which she had two swellings on either side of her body to which she associated sitting between two pregnant women at a dinner party. This was followed by phantasies of attacks on ‘the goose that laid the golden eggs’. Moreover, when she spoke of her feelings of insecurity and inability to maintain her confidence, which she equated with a structure of bricks collapsing, 136 Sydney Klein

it became apparent that this was due to her attacking the cement which bound her together, namely my interpretations. Her own association of cement with semen showed her hostility to the creativity of both parents, who were not allowed to come together in her mind. Nevertheless, there was no overt expression of hostile feelings towards me which remained completely split off. Indeed there was little feeling of immediacy of emotional contact in the transference. Even when she agreed with what I said I did not feel we got any deeper. The model was of a baby with the nipple in its mouth but not taking in the milk. However, after I had consistently drawn her attention to the lack of real emotional contact, in a Monday session a short time later she told me two dreams. In the first dream she was driving up a hill in a red car. Her association was that when she is without me at the weekend she stops going forward and feels like a child. She then told me the second dream in which she was lying in a hospital bed in a room with her mother. There were cockroaches in the room and her mother was very angry with the nurse, while my patient was quite calm. Her associations were that in her late teens she had had an operation for the removal of a dermoid cyst. Her mother came to visit her and was very angry with the nurse because she is very impatient and could not tolerate anything dirty in the room. I interpreted that she was afraid that I was like her mother and could not tolerate anything dirty in her like a cockroach, but this was also because she was putting into me her own impatience and intolerance of anything which was not ideal. She agreed and said rather ruefully that she supposed she expects a land of milk and honey. She then added that she hates cochroaches. She remembered being with a girl friend and killing a big fat cockroach which her girl friend had been very frightened of. She laughed and said it was an act of friendship. Now in the previous session there had been veiled and scattered but increasingly hostile references to this girl friend who had recently started analysis herself and had told my patient she was doing well. It seemed to me that under the guise of friendship she was denying her jealousy of her girl friend who in her phantasy was a new baby coming to me, and I interpreted that she turned me into a dirty cockroach and killed me off because of the hatred and jealousy that she experienced towards me at the weekend as a pregnant mother containing her baby sister and father’s penis instead of being the ideal mother and breast who was Downloaded by [New York University] at 03:54 14 August 2016 there just for her. She said, ‘You have said this before but I don’t see it. I must be blind. It is like looking at letters and not being able to put them together to make words out of them. It is the same with my husband. He gets furious with me and says that I don’t take things in.’ There was a reflective pause and she said, ‘I must be a difficult nut to crack.’ There was another pause and she added, ‘but it’s only like this when you talk about separation.’ I said that she kept herself in a shell in order to avoid the painful feelings I had just described. To summarise, the dream of going up the hill in the car which then changed into a pedal car showed how the patient functioned by identification with me and Autistic phenomena in neurotic patients 137

my analytic potency. However, the fact that this defence failed at the weekend and she regressed to being the helpless child indicates that this identification was predominantly a contact one or what Bick has called ‘adhesive identifications’. In the infantile position her anger with me as the mother containing father’s penis and babies leads her to attack me and turn me into the black cockroach which then has to be killed off. The whole process has been previously encapsulated, i.e. in the dermoid cyst, which had then been dealt with by being cut out. This patient had previously described how her mind drifted away in meetings because she felt afraid of her male colleagues and how she had always felt her father’s words like bullets. In the next session she now returned to this theme and said that she was like a hedgehog; if she was feeling attacked either her quills shot out or she collapsed inside herself. When I interpreted that she was putting her own hostility into myself as father she said she did feel hostile. What was so painful was her feeling that he had no time for her. Every time she telephoned him he just said ‘Hello’ and passed her over to her mother. As a child and adolescent she always felt he was battering her with lectures and had no interest in her feelings or in common everyday events. She then recounted with intense feelings how she used to take her boyfriends home but how they had completely ignored her but sat adoring her father, who also ignored her. It was the most painful experience of her life, she said bitterly. ‘He robbed me of my femininity.’ When I tried to relate this to her feelings about myself and other patients she denied it. She was quite sure this wasn’t so; I was kind, attentive, etc. However, she sounded quite hurt, and I then pointed out how she did feel hurt by me because when I interpreted her negative feelings she felt I ignored her positive, loving feelings. In fact a constant feature of the analysis at this time was that any interpretation of her negative feelings immediately made her feel extremely persecuted. During this period I had to proceed extremely cautiously but little by little she was able to voice feelings and produce dreams in which I was experienced successively as a hard-shelled beaked lobster, a cruel and treacherous Stalin who pretended to be genial but was really murderous, and then as more human but cold, hard and formal. After this period she told me two dreams that shed some light on her difficulty in taking in understanding. In the first dream her husband was talking on the Downloaded by [New York University] at 03:54 14 August 2016 telephone to a young girl who was staying with them and she cut the wire. When I interpreted that not only was she cutting the links between her husband and the girl because of her jealously of the relationship but was also jealous of the link between myself and my analytic babies, she said, ‘I don’t understand.’ I then added that she didn’t understand because she was also cutting the links between us as a result of the envy of the good link between us, and especially the link with the dependent part of herself. She then said, ‘I do understand that. It’s like being in a boat and cutting the ropes pulling me ashore so that no one can help me. I am too proud. I take small things but not big ones.’ She then told me a second dream: She was in the hairdresser’s, and was kept waiting until the shop was empty. 138 Sydney Klein

She then got so angry that she smashed two pairs of plates, each pair consisting of one large and one small plate. Her association was that she had been to the hairdresser and changed her hairstyle but her husband had not noticed. The plates symbolised her capacity to receive and understand the analytic food for thought, which she smashed up when she could not bear the frustration experienced when she felt she was overlooked, especially if she felt I, like her husband, did not notice her attempts to change for the better. Her reaction to this interpretation was to say, ‘My father looked at me but did not see me and never listened either.’ After a pause she said that she now realised that her sexual phantasies towards her father and her wish for babies from him and other men, which we had previously seen, meant that she was prostitut- ing herself to get concrete proof that she was cared for. I told her that if she did not get all the food and care she wanted she destroyed what she did get; it was all or nothing. At a later stage in the analysis, towards the end of the second year, what also emerged was her realisation that she was using me as a processing plant in which I had to act as her eyes and her judgement, and function as someone refining and enriching her like a uranium factory, or giving her a blood transfusion. She revealed that the reason why she projected her senses and her capacity to think into me was that, if she stopped to think and make a decision as to what course of action to take, she was afraid that she would become so paralysed by doubts about other possible courses of action that she would never move. Instead she got rid of her capacity to think, and consequently behaved in a completely blind and confused way. This was described very vividly by her as pseudo-bravery, in which she acted very fast and destroyed what she called the monsters of doubt which made her behave in what she called ‘constant hysterical action’. It also became apparent that her paralysis by doubt was due to her fear that if she went ahead and committed herself to the analysis, this would result in her throwing herself completely into me, body and soul. This was partly due to her need to prove her commitment as a result of the projection of her expectations from others, particularly her father and myself. She admitted that she had always felt she needed her father’s whole physical involvement because she had had so little of it as a child. At the same time her fear of throwing herself inside me was due to the impulse Downloaded by [New York University] at 03:54 14 August 2016 to occupy and possess me as a mother full of imagined riches. This was felt as being carried out in such a violent way that she feared that she would get stuck inside me and would be unable to extricate herself. Even worse, she feared that in the process she would destroy my inside containing herself, expressed in phantasies of being buried alive in a mining shaft whose walls collapsed, a volcano erupting with tons of lava and a steamroller which could flatten everything. However, as another holiday drew nearer at the end of the second year, it became clear that behind the possessiveness and jealousy of her more adult self, there was a desperate need to keep herself inside me because of the intense anxiety aroused in the infantile part of her by the approaching break. This time the Autistic phenomena in neurotic patients 139

impending separation brought into consciousness terrible feelings of me dying or abandoning her and of consequently dying or falling to pieces herself. She said she felt as if she were in a black space screaming for help. ‘I feel worse than an unborn baby, more like a mindless dog which can only be happy when its master returns.’ These primitive feelings of needing the analyst/mother in order to hold the infant together and prevent it from death and disintegration are basically what underlie the autistic defences I have previously described. The patient herself referred to her behaviour being like that of a child playing with a ball, that could not stop (just as I described the behaviour of the autistic child) because any suggestion of the idea of it not going on for ever was like a small dose of death. The interpretation of these intense anxieties brought a measure of relief to the patient but then led to phantasies that she could only get stronger by eating her way out of me and guilt at taking in life at my expense. As this was due to the feeling of being inside me again we could then see that apart from the primary infantile anxiety of separation she also got rid of the adult part of herself in order to make herself small enough to get inside me like Alice in Wonderland, this time because of a stubborn anger and spite at the separation. For the first time she was able to admit to murderous feelings about being left, both towards myself and towards the other babies felt to be taking her place inside, and in particular anger at being made so much better that she could no longer regress to being the helpless infant. This patient and others like her had a preoccupation with and a fascination for words. On one occasion when her husband had been away and not replied to a letter she had written him, she dreamed of a letter being wrapped in wool. The meaning of this dream was that no-words were experienced as cold and hostile. Similarly, in order to disguise her own hostile reactions she had to wrap up her own words to make them warm. This sensitivity to the analyst’s tone of voice, which is partly due to the need to hang on to something for life and support and partly due to the expectation of hostility, requires him to be alert to his own reactions. While there is no doubt that the visual deprivation caused by lying on the couch plays a part in the importance of the analyst’s voice, it also has its roots in early infancy. My patient’s earlier difficulty in expressing her feelings seemed to be due Downloaded by [New York University] at 03:54 14 August 2016 partly to identifying me with a fragile mother who could not stand anxiety without breaking down, and partly due to identifying me with an omnipotent father who would crush any aggression or defiance or reject her love. It was this lack of a good stable container which I think led her to use her body as a container instead, with the consequent production of psychosomatic symptoms. In fact all my patients in this group experienced their mothers as anxious, insecure, controlling, over-protective and hypochrondriacal, while their fathers were described as being either physically absent in their childhood or emotionally absent in the sense of being remote intellectuals heavily invested in academic or professional interests outside the family. However, the patient’s material about being battered 140 Sydney Klein

by words and her excess of concrete thinking seemed to be related at a deeper part-object level to attacks by an object which contained by production the split-off hostility aroused by a frustrating nipple and the need to preserve it from this hostility and the additional aggression towards this object for taking the infant’s place. In this connection I should like to mention that my patient had made various references to guilt and anxiety about incest. A dream in which her body was split in half was understood in terms of splitting off her sexual feelings from her oral ones. In the context of the session this led me to suppose that this incest taboo was originally based on the guilt and anxiety caused by primitive sexual feelings and desires directed towards the nipple which was felt at the same time to be in danger of being destroyed. In this connection it is striking that for many years there seemed to be a taboo on the word nipple in the analytic literature. Although Freud used the word as early as 1905 in his paper on ‘A Case of Hysteria’, even Melanie Klein hardly ever used it in spite of her voluminous writings on orality, and there have only been scattered references to it since, as Bradley (1973) described in his well-documented paper. A systematic differentiation of the nipple as a structure separate from but part of the breast, the confusion of nipple and penis, etc. was first described by Meltzer (1963), i.e. nearly 60 years later. Confirmatory material was furnished by another patient who described how his four-week-old baby girl started to cry when he stopped talking to his wife when she was feeding the baby. As soon as he started to talk again the baby settled down. A few weeks later the reverse occurred. When he began to speak to his wife during feeding, the baby began to cry. In the context of the session it appeared that there is a change from an early experience of a good third object felt to be supporting the nipple to one in which it becomes hostile and intrusive. In others words, the absent third object, later called ‘father’, is experienced as what might be called an aggressive masculine nipple. This was shown in a dream in which the patient was being run down by a Jaguar car with a small rubber protrusion at the front to which he associated a teat on a bottle. Now, as Bion (1957) has pointed out, the fragmentation and projection of the sensory apparatus by the psychotic part of the personality leads to a penetration and encystment of the object which then swells up with rage. As a consequence words are not experienced as words but as hostile missiles, as my patient Downloaded by [New York University] at 03:54 14 August 2016 described. Seen in this light the acute cystic swellings of the patient I have described in detail can also be understood as being due to phantasies of projection of aggressive feelings and parts of herself into her internal objects, namely mother’s nipple, breast and reproductive organs, which then swelled up and became persecutors. Bion also describes how in an earlier phase of development, i.e. pre-auditory, the infant has difficulty in using ideographs to form words. My patient’s reference to not being able to put letters together to make words is relevant here and was due both to her attacking the links between objects and losing the capacity to restore them. In connection with the projection of the sensory apparatus it is interesting that another patient who was much more Autistic phenomena in neurotic patients 141

disturbed had a dream in which an old-fashioned gramophone horn was listening to him. In this case the capacity to hear had been projected so that the gramophone was then felt to be listening instead of playing. At a later stage he also dreamed of looking at a breast which had an eye in the centre looking at him, so that here the capacity to see had been projected. To summarise, the autistic defence is primarily due to the avoidance of the pain caused by the intensity of the fear of death and disintegration caused by the absence of the containing nipple or breast. This surfaces as analysis progresses, not only at weekend and holiday separations but every time the patient makes a step forward and becomes more separate. In the patients I have described, these anxieties had previously been avoided either by projective identification with me and phantasies of being unborn and living inside me, by introjective identification with me as a hard-shelled object and by adhesive identification leading to clinging to me as a placenta-like object which both feeds and detoxicates at the same time. The impact of these terrifying feelings on the analyst may be considerable as they may have been previously modified by the reassurance gained by the fact that he usually retains professional contact with his own analyst or institute or indeed by using the institute itself as a container. Technically, it is obvious that the patient’s sensitivity to the tone of the analyst’s voice must be matched by the analyst’s equally sensitive but non- paranoid alertness to the underlying tone of voice and mood of the patient. In a previous paper on mania I described how the manic patient talked incessantly as a defence against feelings of inner emptiness. The type of patient I have described here does not, of course, have the same degree of disturbance, but it was notice- able that they were all extremely verbally fluent and two were informed by their parents that they could talk before they could walk. It seems that the premature development and hypertrophy of speech may be partly a defence against underlying feelings of emptiness and non-existence and partly to overcome the infant’s anxiety that these primitive feelings are not understood and contained. This precarious situation becomes confounded when the hypochondriacal mother uses the infant as a container for her own anxieties. In any event, speech was certainly used by these patients at certain periods either to maintain a link with the analyst or to avoid the link, rather than as a means of communication. In other words, we have to recognise that although the patient appears to Downloaded by [New York University] at 03:54 14 August 2016 communicate at one level there is also a non-communication corresponding to the mute phase of the autistic child, and that what is not communicated are not only the aggressive but also the loving feelings which accompany the growth of the sense of separateness and the associated sense of responsibility for the self and objects. At the last IPA Congress, Limentani (1977) also stressed the importance of learning to understand the moods and feelings of the silent patient and his difficulty in conveying his experience to students and colleagues. Is not this paralleled by the difficulty the pre-verbal infant has in conveying his sensations and feelings to his mother, especially the experience of being alone in a silent world? 142 Sydney Klein

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 – namely the process of oscillation, which repeatedly occurs, for example, between states of omnipotence and helplessness, activity and passivity, adulthood and infantility, psychosis and neurosis, primitiveness and sophistication of thought, and paranoid schizoid depression. Analysis of the oscillation leads hopefully to a more balanced state of mind and personality, in which the knife-edge of opposites is broadened to become a more solid basis of reflective thought.

Note 1. Originally published (1980), International Journal of Psycho-Analysis, 61: 395–402. Downloaded by [New York University] at 03:54 14 August 2016 Chapter 10 Precipitation anxiety in the analysis of adult patients

Didier Houzel

The hypothesis I formulated under the name ‘precipitation anxiety’ (Houzel 1989, 1995) gradually took shape in my mind as a result of working with autistic and psychotic children at a time when I was fortunate enough to be in supervision with Donald Meltzer and Frances Tustin. I am indebted to these two supervisors for inspiring the idea. The first inkling I had came from a sequence in the therapy of a psychotic boy, a therapy supervised by Donald Meltzer. I was treating this boy with three sessions per week, and at the time he was about twelve years of age; there were unmistakable references in the material to sexual themes, which I linked to the onset of puberty. One day, he covered two little dolls, one male and the other female, with modeling clay, then dashed them violently one against the other. Donald Meltzer suggested that the modeling clay might represent the sexual energy – the libido – attributed to the two dolls, and that their violent coming together might relate to a fantasy in which sexuality, untransformed by mental processes, remained crude and primitive, and was therefore expressed as an irresistible attraction, violent and destructive. The second indication I had was drawn from the therapy material of an autistic boy, who had four sessions a week with me; this therapy was supervised by Frances Tustin. At one point, the boy turned his box of pencils upside down, with a loudly exclaimed ‘Crash!’ Tustin suggested that, in the context, he was expressing a fantasy of being catapulted into birth, experienced catastrophically as

Downloaded by [New York University] at 03:54 14 August 2016 a destructive collapse. In both instances there was a representation of an energy gradient creating an irresistible force of attraction that was experienced as violent and destructive: in the first case the source of the gradient was sexual attraction, in the second the caesura of birth. The ‘dynamics of the gradient’ began to interest me more and more, and led me to put forward the hypothesis of precipitation anxiety. That there could be fantasies relating to gradients of energy opened up a whole new field of psychoanalytic exploration for me. Hitherto, I had considered therapy material in both children and adults – and indeed psychoanalytic theory in general – mainly 144 Didier Houzel

in terms of conflict: two antagonistic forces pulling in opposite directions. This was quite clearly Freud’s perspective in his first theory of the instincts, where he contrasts ego instincts and sexual instincts. The notion of gradient dynamics is not, however, entirely absent from Freud’s thinking: it appears in his second theory (Freud 1920), where he contrasts life and death instincts. Perhaps it has not been sufficiently acknowledged that in this model we can no longer see two opposing forces locked in battle; here, there is a gradient of energy between two poles, one of which is situated at the virtual extremity of an axis which goes from least to most organized, completely unbound to highly bound, while the other is located at the very real extremity of the same axis where unbinding is at a maximum. Freud could not describe these two new drives in terms of the dialectics of conflict. The life instinct, he declared, permits no more than a temporary stay in the organized end of the spectrum before the inevitable return to the non-organized. This is one way of saying that sooner or later a return to a minimal level of energy is inevitable in gradient dynamics, once there is no longer any external input of energy. As we all know, this second theory of the instincts created a split among psychoanalysts, many of whom have never accepted it. Freud himself never clearly demonstrated how it could be applied to psychoanalytic technique or further our understanding of the therapeutic process. He admitted that what he was saying was speculation, though the idea itself was based on clinical data – the repetition of traumatic situations in the dreams of patients suffering from traumatic neuroses (especially war neuroses), and the repetition in children’s play of traumatic situations, in particular experiences of separation, as illustrated in the famous Fort-da game with the wooden reel. Melanie Klein was the first to place the gradient dynamics of this second theory of the instincts at the heart of her theoretical developments. For that reason, in my view, she was able to treat successfully by psychoanalysis those pathological conditions in which this aspect of mental development prevails over the dynamics of conflict: the psychoses, borderline states, narcissistic pathology. It was thanks to her lead that some of her pupils were able to use psychoanalysis to explore autism and the autistic enclaves lying at the heart of many psychopathological disorders in children, adolescents and adults. My own two supervisors, Donald Meltzer and Frances Tustin, following in the steps of Melanie Downloaded by [New York University] at 03:54 14 August 2016 Klein, made decisive progress in exploring the world of autism. I shall clarify below the links between the hypotheses I am putting forward in this chapter and the theoretical developments of each of these writers. But let me first explain my own hypotheses and illustrate them with clinical material.

Personal hypotheses I postulate that every object relation is established as a result of a caesura which creates a gradient of psychic energy. This energy gradient is experienced initially as a precipice, pulling irresistibly towards downfall and destruction. Precipitation anxiety in the analysis of adult patients 145

If the encounter with the object is to become possible, the gradient must be regulated in such a way that it can be negotiated without damage. Mental communication with the object enables this adjustment to take place: every time such communication is successful, it is as though a new level of stability is created on the slope down into the precipice. In this way, the self’s advance towards the object is secured and there is no danger of a destructive collapse. I am borrowing the word ‘caesura’ from W. R. Bion, who used it to describe the passage not only from intra-uterine to extra-uterine life – the ‘caesura of birth’ – but also from any one phase of existence to another. Bion emphasized that every caesura requires transformation of the psychic experience preceding the caesura, in order to integrate it into mental life as it will be after the caesura has occurred. If something remains in its pre-caesura state and is not transformed in this way, it will be a source of mental impairment and suffering. I would suggest that Bion’s words could be reformulated in terms of disruption and continuity: the caesura brings about a collapse of relational continuity with the external object and the mind has to replace this with relational continuity with the internal object. This new continuity can occur only if the energy gradient created by the breakdown in relational continuity with the external object is adequately regulated. Successful communication and encounters between self and object create the requisite adjustment; they modify the downward slope to the precipice opened up by the caesura. Traces of these successive modifications are stored in the mind and create an inner world which is complex, self-regulated, endowed with life and creativity, and stable enough to withstand the vicissitudes of life without undergoing major disorganization. Bion called this process of self- regulation of the internal world ‘mental growth’. If the self does not have satisfactory encounters with objects which promote mental growth, it has to face an unregulated gradient, experienced initially as a bottomless pit then as an uncontrollable acceleration. I could use the term ‘precipitation anxiety’ with reference to the spatial image of a precipice, and ‘acceleration anxiety’ with respect to the second model, which is more temporal than spatial. However, since in both English and French the word ‘precipitation’ has this double connotation of space and time, I shall use ‘precipitation anxiety’ as a generic term to cover both aspects. Looked at from a spatial point of view, precipitation anxiety is the kind of Downloaded by [New York University] at 03:54 14 August 2016 anxiety which autistic children experience and against which they try to defend themselves. The first beginnings of an object relation generate tremendous anxiety in autistic children, probably because they were unable in their initial experiences to communicate either mentally or – even more fundamentally – emotionally with the object. It is as if every object relation, every awareness of separation from the object, reawakens fantasies of a primeval precipice into which they will be dragged down and annihilated. Their only possibility of combating annihilation anxiety is to attempt to nullify the energy gradient created by the caesura of birth by denying any separation, avoiding any awareness of otherness, struggling to keep everything at a standstill, blocking change and 146 Didier Houzel

freezing time. Autistic mechanisms may succeed in stemming precipitation anxiety, but they also prevent mental growth.

A clinical illustration The example I propose to present is taken, not from the analysis of an autistic child, but from that of an adult patient who is borderline psychotic. With this kind of patient, we invariably come up against autistic nuclei at one point or another in the analysis – especially when the rhythm of the sessions is modified for some reason. The patient whom I shall call ‘Jerome’ is a good-looking man in his thirties. He sought analysis seven years ago, one year after the death of his father from a brain tumor, because he felt increasingly anxious and was afraid he might be going mad. He has been living for the past two years with a young woman; at the time of the sessions I am about to report, she was pregnant. On several occasions Jerome described the domestic quarrels that took place between them; these had increased in frequency and in violence since the beginning of her pregnancy. Also, he has just begun an affair with another woman, an affair he experiences as extra-marital; indeed, he refers to this woman as his ‘mistress’. He felt he was justified in having this relationship because of the domestic quarrels I have mentioned and the fact that his partner has lost almost all interest in sex since she became pregnant. He does, however, feel very guilty. He has never had any kind of sexual problem before, but with his ‘mistress’ he is impotent. For the first three years of the analysis, Jerome had three sessions per week. For the following three years, the frequency was increased to four sessions weekly. This past year, we have had to scale down to two sessions per week because he has moved house and now lives more than 60 miles from Caen (the removal was linked to his cohabitee’s employment). An additional factor is that the sessions I am about to report took place after the summer vacation break. Jerome’s later childhood and adolescence were apparently uneventful. His early childhood, however, was marked by several serious medical mishaps. When he was only a few weeks old, he was poisoned by medication given him in a massive overdose. He began convulsing and had to remain in hospital for several weeks; it Downloaded by [New York University] at 03:54 14 August 2016 was feared that he would not survive. That hospitalization, of course, meant an abrupt separation from his mother. His parents seem to have been extremely worried by this event, to the extent that, thereafter, they treated him as a fragile child who had to be protected at the first sign of danger. When he was just one year old, the trauma of separation was repeated: he had to be re-hospitalized for asthma-related bronchitis. The session material I present seems to me to be a good illustration of what I call precipitation and the anxieties that are attached to it, especially the dream in which Jerome finds himself falling into an infinite void. Conflict is present in this theme, but on a primitive level rather than on an Oedipal one. We could say Precipitation anxiety in the analysis of adult patients 147

that the patient is describing how he failed to make a strong Oedipal contact with a father figure in an encounter that would help him process his precipitation anxiety. The link between this issue and Jerome’s significant communication problems is obvious: it is as though excessive parental protection – in particular by the father – had imprisoned Jerome in a false identity and prevented him from communicating his very real feelings of anxiety. As a result, in the absence of a containing relationship with his parents, he remained unable to process these primitive anxieties.

20 August 2002 This session took place after an interruption that had lasted six days. It took Jerome several minutes before he started talking, and even then only in a very quiet voice that I could not quite hear properly. I made the comment that I was finding it very difficult to understand him. He then spoke in a louder voice, saying that he felt shut in, like a horse in a stall or as if he were inside an egg and couldn’t break out. Then he told me of an anxiety dream he had had on Sunday night. Earlier that evening, he had quarreled with his girl-friend, who thereupon went to bed in another room. He had therefore slept alone that night. I asked him to tell me more about the dream. He said he remembered that it was in two parts. In the first,he felt he was falling down into a void, an infinite nothingness; in the second, he was punching his pregnant girlfriend in the stomach. At that point, he woke up. He told me that, ever since he was a boy, he has had this feeling of endlessly falling; it would occur quite often. In his childhood, it was mainly when he thought about death that he had this feeling. In the session, he went on to talk about generations succeeding each other, with the idea that later generations push out previous ones; he linked this to the fact that his girlfriend was expecting a baby. I linked the dream to the fantasy that we had discussed together in the previous session, in which he had seemed to be identified with the baby in his girlfriend’s womb, as though to avoid any sense of awareness of separation. In the dream, it was as though he were becoming aware of separation, and in particular of sepa- Downloaded by [New York University] at 03:54 14 August 2016 ration-in-the-analysis; I reminded him that this was the first time in six days that we were together, adding that awareness of separation seemed to give him the feeling of being precipitated into an endless void. I went on to say that he then turned against the maternal space occupied by the baby and attacked it – perhaps he was imagining other analysands occupying the analytical couch. Jerome then spoke about Winnicott’s Playing and Reality, part of which he had re-read just recently. He recalled in particular the passage where Winnicott writes of a child who joined everything up with string. He said that a thought had just flashed through his mind – he wondered how I had spent the week – but he was unable to pursue that thought, as though his thoughts were not joined up together. 148 Didier Houzel

He added that he could not think of anyone else at that point except his girlfriend. Then he thought of the woman with whom he was having an affair; he hadn’t had any news of her until the beginning of the week, the day before in fact. Normally they were due to see each other the following day. He thought about how, sexually speaking, things were not working out with her, something that worried him very much – it was as though he were unable to penetrate her physically. He added that deep inside himself there were very violent and angry feelings. I pointed out that the string in Winnicott’s paper was equivalent to links, and that Jerome was talking about linking up his thoughts as well as about linking up, in thought, with people who were absent. I commented that he was perhaps afraid he would attack the links that tied him to other people and prevented him from feeling as though he were endlessly falling – and maybe even destroy them, as when, in the dream, he attacked his pregnant girlfriend in the stomach, or when he wanted to penetrate another woman, or penetrate into my private life by wondering how I had spent the week. I spoke of a vicious circle that could perhaps give him the impression that the world was folding back in on itself, leaving him no way of escape; in order to avoid feelings of falling into an endless void after leaving the maternal womb, i.e. at birth, he had to have some kind of encounter with another, separate and distinct, figure. (I was thinking that the baby in the womb represented the other analysands occupying the analytical space, the previous generation, as it were; I linked this to an image of the analyst as a separate and distinct paternal figure whom Jerome was at the same time afraid of encountering in the analytical space – just as he was afraid of what he might come up against were he to penetrate sexually the woman he referred to as his mistress.) If, however, he did meet up with such a figure, he would be afraid he might attack and destroy the links that prevented him from feeling he was falling endlessly into an infinite void. He agreed that he did in fact feel that the affair he was having with his mistress might pose a threat to his relationship with his girlfriend and their baby. Then he spoke of how difficult it was for him to attend his sessions, in contrast to the desire he had felt, during the actual separation, to see me. In fact he had put off until the last minute any attempt to schedule this session, as if he’d been afraid of not being able to reconcile everything: his relationship with his girlfriend, the baby, the affair with his mistress, his job, and the sessions. He spoke in the same Downloaded by [New York University] at 03:54 14 August 2016 vein about his thoughts, saying that he found it difficult and sometimes even impossible to reconcile all his thoughts inside his head. I added that perhaps, too, when he came to the sessions, he was afraid he might attack and destroy the analytical links – whereas, when he was at some distance from the sessions, that fear diminished in intensity.

21 August 2002 Jerome began the session by saying that he still felt imprisoned inside himself; he compared this feeling to an actor on the stage who found it impossible to exit. Precipitation anxiety in the analysis of adult patients 149

He added that he did, all the same, feel more relaxed than the previous day. He associated from this to one of Winnicott’s articles, in which there is something about the symbol taking over from the object. Jerome interpreted that statement as meaning that there could be another object inside oneself that both prevented one from thinking about the absent object and obviated any need to do so. Then he spoke of the illness he had suffered from as a baby, saying that it was the same feeling as when he was ill and felt enclosed inside his illness without any real communication with the outside world. I commented that, in my view, his childhood illness must have worried his parents a great deal; perhaps from then on he had been treated as a ‘fragile’ child who had to be protected – rather than as one who had to be helped to face up to things in the way we had talked about in the previous session. I added that he was perhaps having such a feeling again, this time within the analytical relationship – being shut into a role as a fragile child who had to be protected (that indeed had been my fantasy when I offered him some sessions in August, though I had not in fact mentioned that to him). He then said he was thinking about his father, with whom he had almost never had any kind of stand-off – sometimes, for example, his mother would step in and turn things around. He felt that, because of this, all conflict took place inside himself, since there was nobody outside that he had had to face up to. He added: ‘That’s what coming out of an egg means: breaking the shell, leaving behind the fragile child’s skin.’ Jerome remembered that, during his adolescence, his friends had thought that his parents were great people, so cool and interesting. He remembered one of his friends saying that to him; Jerome had felt dumbstruck, he just did not know what to say. ‘How could anyone have a stand-off with parents like that,’ he added, ‘and how could anyone ever manage to leave them and move on?’ He thought again about his childhood illness and about what his mother had said to him about it. After leaving hospital, there had been complications; she had had no idea how to cope with them, she had felt very anxious, and the pediatrician had admonished her, saying: ‘If you go on like that, you’re going to make a mess of that kid.’ After that, however, things had been really fine for a time, with good communication between mother and child. There had been another short hospitalization when he was about one year old, for a bronchitis- Downloaded by [New York University] at 03:54 14 August 2016 related ailment; this second spell in hospital seems to have put an end to that idyllic period. He then spoke in a very perceptive way about his pregnant girlfriend and her apparently dramatic mood swings. The gynecologist whom she had consulted the previous day had reassured her, saying that it was quite a normal occurrence in pregnant women. When Jerome spoke to her on the phone the evening of the day before, he had the idea that these mood swings were perhaps useful as a preparation for the baby’s arrival and for establishing a relationship with the baby after birth; he associated again to the time he had spent in hospital as a baby, saying that perhaps the hospitalization had prevented him and his mother from further 150 Didier Houzel

developing that kind of process between them. He compared this to breaks in the analysis. He again mentioned the other person inside himself who stopped him thinking about the absent other, adding that it was just like breaks in the analysis – he felt I was ‘occupying’ him, so that he could not think of me as being absent. I said that perhaps he felt ‘occupied’ by parental images that were worried and protective, and that that prevented him from communicating with his real parents – just as he might have felt them to be ‘occupied’ by an image of Jerome as ill and fragile, so that they too had been unable to see in him the child he really was. That kind of situation, I added, continued into the analytical relationship whenever he was ‘occupied’ by an image of me rather than allowing himself to think about my absence, and whenever he found it difficult to come back physically into the sessions. Jerome replied: ‘When I’m a good boy, I’m a sick boy. I get “being good” and “being ill” all mixed up.’ In this chapter, I lay particular emphasis on that aspect of object relations and mental functioning which encompasses gradient dynamics. The reason is that it is precisely this aspect which, in my view, corresponds to the anxieties and fantasies we encounter in psychotic and autistic disorders, and, further, these anxieties and fantasies constitute what I call ‘precipitation anxiety’. I must make it clear that I am not proposing simply to replace the idea of conflict with that of gradient, or to substitute gradient dynamics for what traditional psychoanalytic theory describes in terms of conflict dynamics. My view is that both must exist for mental growth to take place, and that between gradient dynamics and conflict dynamics there is a sequential relationship which is the exact converse of the order in which they were discovered. Freud described conflict dynamics in his first theory of the instincts and then, after 1920, turned his attention to gradient dynamics in his second theory. We have to see them in the reverse order if we are to articulate both types of dynamics in our understanding of mental development. In order for conflict dynamics to exist as such, they must have been preceded by the experience of working through gradient dynamics. Conflict is vital in its own right in order for mental growth to develop, in particular for the individuation of the child with respect to his or her mother. Without conflict, the two sides of the interface I described earlier would remained indissolubly Downloaded by [New York University] at 03:54 14 August 2016 merged. The regulatory adjustments I mentioned above may indeed materialize – but with so much identity confusion that the internal world of one or both participants in the relationship would be terribly damaged, as we see, for example, in schizophrenic breakdowns. Jerome’s second session in particular seems to me to support the hypothesis that there is a degree of correspondence between gradient dynamics and the maternal pole of object relations, and between conflict dynamics and the paternal pole. In the reality of the child’s experience of his or her parents, these two aspects extend over the relationships with father and mother. The Oedipal configuration is another way of expressing the unequal distribution, depending Precipitation anxiety in the analysis of adult patients 151

on the sex of the child, of these two aspects of object relations and mental functioning which I have described respectively in terms of gradient and conflict dynamics.

Precipitation anxiety and the aesthetic conflict In 1987, Donald Meltzer introduced an entirely novel – and remarkably fertile – hypothesis into traditional psychoanalytic theory: that of a gradient of the unknown between the outer or surface qualities of the object, those which the new-born can perceive at birth, and its inner qualities, which are initially inaccessible. Meltzer gave the name ‘aesthetic object’ to this primary object which generates such intense sensations that they create an aesthetic emotion; he terms ‘aesthetic conflict’ the dilemma the new-born faces when confronted with what I am here calling the ‘gradient of the unknown’ between the external and internal qualities of the object. According to Meltzer, the infant tries to resolve this dilemma through the use of epistomophilic drives, with the aim of discovering the hidden, internal qualities of the object – in other words, those of the mind. Meltzer stresses what he calls ‘aesthetic reciprocity’ in the mother-child relationship. The infant’s aesthetic experience must find an echo in the mother if the conflict is not to appear immediately insuperable and insoluble to the child. To the latter’s perception of a ‘beautiful enough’ mother must correspond the mother’s vision of a ‘beautiful enough’ baby; by drawing support from this encounter – the bedrock of narcissism – infants can set out to explore the inner- most qualities of the object as they construct their own inner world. There is obviously much common ground between Meltzer’s hypotheses as regards the aesthetic object and aesthetic conflict and my own proposals concerning precipitation anxiety, in particular:

• the idea of a primary gradient that is created by the caesura of birth and upon which the relationship with the object is established; • the idea of the encounter – an emotional encounter – between infant and mother as the basis for constructing the internal (psychic) world.

There are, however, zones of uncertainty or even of disagreement between Downloaded by [New York University] at 03:54 14 August 2016 Meltzer and me, and I would now like to try to delineate these. Meltzer emphasizes the aesthetic aspect of the infant’s primary experience with the object, the paradigm of which is the maternal breast. He does point out, of course, that the aesthetic experience is fundamentally an emotional and not an intellectual one. I feel, nevertheless, that the dynamic dimension of the infant’s early relationship to the object is insufficiently accounted for. To my mind, it is not simply because the object is externally beautiful and unknown in its inner depth that the infant is faced with a dilemma which must be resolved if the relation to the object is to be experienced as helpful and supportive rather than destructive; the point surely is that the object is seductive – by its sheer presence, 152 Didier Houzel

it pulls the infant mind irresistibly into its gravitational field. Only a psychic encounter with the object can slow down this attraction without stopping it altogether. That is why the infant needs to explore the internal qualities of the object, because psychic encounters are necessary if the mind is to maintain adequate ‘structural stability’ and be allowed to grow in more and more complex ways. I also agree with the French psychoanalyst Jean Begoin when he says that it is not the object per se which is beautiful, but the encounter with the object. It would be better to speak of the beauty of the encounter between self and object rather than of the beauty of the object per se. To summarize, what I am proposing is a dynamic reading of Meltzer’s theory of the aesthetic conflict. The object is initially fascinating for the self, which it pulls into its gravitational field with an irresistible violence experienced as destructive unless it is tempered by those mutual encounters which Meltzer calls ‘aesthetic reciprocity’. I imagine these encounters to be the convergent movements of both partners to form a zone of stability; without this reciprocal convergence there would be nothing to brake the downward plunge into the endless void. It is not only aesthetic reciprocity which is required, but also reciprocal seduction, so that to the attraction of the nascent psyche of the infant for the mother corresponds the attraction of the mother’s mind for her child.

Precipitation anxiety and premature psychological birth The term ‘premature psychological birth’ was originally Frances Tustin’s (Grotstein 1981a). I would include in the expression all that she has contributed to our understanding of autism in children and of what she first called ‘autistic enclaves’, and later ‘autistic barriers’ encountered in various psychopathological disorders in children, adolescents, and adults (phobias, anorexia nervosa, addictive tendencies, psychosomatic illnesses, borderline states, etc.). Frances Tustin states that if a baby becomes prematurely aware of the fact of physical separateness as regards the mother, he or she will be faced with catastrophic anxiety which takes the form of a black hole filled with persecutors. Ms Tustin emphasizes that it is because the child does not have the mental capacity to confront the experience of separateness that such anxiety arises; it is as Downloaded by [New York University] at 03:54 14 August 2016 though the baby were unable to bridge mentally the discontinuity created by the gap between the self and the object of drive satisfaction. This discontinuity is experienced in a very concrete and physical way: as though part of his or her own mouth had been torn off, hence the impression of a ‘black hole (Tustin 1981:91) with a nasty prick’, the fantasy of a ‘breast with a broken nipple’, and the loss of ‘mouth-tongue-nipple-breast’ continuity. The autistic mechanisms (the constitution of a ‘protective shell’ made of autosensuality, autistic objects and sensations) aim at stemming this anxiety, which is revived every time an object relation is about to begin. I have no need to develop further this fundamental feature of Tustin’s discoveries as regards autism. Precipitation anxiety in the analysis of adult patients 153

My hypothesis concerning precipitation anxiety fits in perfectly with Frances Tustin’s ideas, as long as they are properly interpreted and the accent is laid on the dynamic aspect of the autistic experience. Frances Tustin quite clearly states that it is the awareness of the physical separateness between self and object which is involved in autistic experience, and not the mere fact of the separation itself. She is not describing a disorder which occurs as a reaction to a life event (the inevitable separation between infant and mother or maternal breast). The point at issue is quite different: a state of mind where there is failure (or lack of sufficient resources) to bridge a gap which is felt to be insuperable and therefore experienced in the catastrophic way I have mentioned. We could go further and say that the ‘black hole’ corresponds to the dynamic aspect of this same state of mind. The ‘black hole’ is not merely the result of deprivation, or some kind of reaction to a frustrating situation created by the object; it has to be understood in a way similar to the ‘black hole’ image of astro- physicists – a core that engulfs all mental substance, sucking it into a gravitational field so powerful that nothing can escape. I myself suggested to Frances Tustin the term ‘separability from the object’ to describe the experience which the autistic child faces and cannot work through. She agreed that this was an accurate reading of her argument. The issue is the discovery of ‘separability from the object’ and not the fact of separation per se. The crucial point is the gap created between self and object: the autistic child fights against recognition of separability, acknowledgement of the gap which he or she cannot bridge without destruction. It is an abyss down into which the infant is sucked with such momentum that it becomes impossible to approach it without feeling threatened with annihilation. It is precisely because of the failure to establish a primary relationship between mother and baby that the autistic child is locked into a state of mind where recognition of separability is impossible. The most prominent risk factor for autistic development is maternal depression after childbirth. A depressed mother is not an absent mother; she is physically present and able to take care of her infant’s physical needs, but she is unable to establish contact, especially emotional contact, with her baby. A relationship with a depressed person is something we can all experience, and it is quite different from experiencing frustration. It is Downloaded by [New York University] at 03:54 14 August 2016 more like the terribly disquieting impression of being dragged into infinite space, with nothing to counter this morbid attraction, nothing solid, nothing to fall back on. This, in my view, is the kind of experience an infant has with a severely depressed mother who cannot, by the child’s exertions alone, be brought back to mental life.

Conclusion In psychoanalysis, the best theoretical hypotheses are those which originate in our clinical practice. Our sources of inspiration are therapies with different kinds of 154 Didier Houzel

patient, the nature of the material they bring, our attempts to think through this material, and the therapeutic processes which these attempts set in motion. Now that I have explained the theoretical models and examined them from different points of view, it is logical to return to the clinical situation and ask how the developments they have enabled us to make can promote better understanding of the material and further the treatment process itself. This is what I shall attempt to do now in concluding this chapter. The model I describe, in which gradient dynamics precede conflict dynamics, can help us improve our understanding of the clinical material in certain kinds of treatment or at certain moments in all therapies. Firstly, it accounts for the well- known fact that the setting governs the therapeutic process it contains. The setting is not something passive, a mere conventional time and place where analyst and patient meet; it is a dynamic container which must possess the requisite features for receiving all that the analysand is communicating, consciously and unconsciously, without letting anything fall into a void from which it might never return. The other technical consequence of my thesis is that in some therapies, or at certain points in any therapy, the material the patient brings is to be read not as a message (conscious or unconscious) addressed more or less intentionally to the analyst, but as a kind of inventory or theatrical representation of the patient’s inner world. For example, a child who scatters objects all over the consulting room is in all probability showing the analyst how he or she feels inside: in disar- ray, scattered all over the place. The intentionality of the message does not lie in its content – it would be a mistake to say in such a case: ‘You’re making a mess in order to tell me how angry you are with me.’ It lies in the very fact that the young patient is searching for a container (in Bion’s sense of the word) for those

Downloaded by [New York University] at 03:54 14 August 2016 parts of the self which have never succeeded in finding one, and which as a result have never been taken up into a mind which could think them through and process them adequately. Chapter 11 On the concept of an autistic-contiguous position Thomas H. Ogden

Introduction The exchange of ideas constituting the British psychoanalytic discourse of the 1930s to the early 1970s revolved in large part around the work of Klein, Winnicott, Fairbairn, and Bion. Each of these analysts provided the context for, as well as a counterpoint in relation to which, the others generated their ideas. The history of the development of British object-relations theory of the last twenty years can be viewed as containing the beginnings of an exploration of an area of experience that lies outside of the states of being addressed by Klein’s (1958) concepts of the paranoid-schizoid and depressive positions, by Fairbairn’s (1944) conception of the internal object world, by Bion’s (1962b) conception of projective identification as a primitive form of defense, communication and containment, or by Winnicott’s (1971) conception of the evolution of the mother-infant relationship and the elaboration of transitional phenomena. The clinical and theoretical work of Esther Bick (1968, 1986), Donald Meltzer (1975; Meltzer et al. 1975), and Frances Tustin (1972a, 1980, 1981, 1984b, 1986a), developed in the context of their clinical work with autistic children, has served to define a heretofore insufficiently understood dimension of all human experience (more primitive than the paranoid-schizoid position) that I will refer to as the autistic-contiguous position. The present paper represents a synthesis, interpretation, and extension of the work of these analytic thinkers. (A partial Downloaded by [New York University] at 03:54 14 August 2016 listing of other important contributors to this area of investigation includes Anthony (1958), Anzieu (1970), Bion (1962b), Bower (1977), Brazelton (1981), Eimas (1975), Fordham (1977), E. Gaddini (1969), R. Gaddini (1978), Kanner (1944), S. Klein (1980), Mahler and Furer (1968), Milner (1969), D. Rosenfeld (1984), Sander (1964), Spitz (1965), Stern (1985), Trevarthan (1979) and Winnicott (1960b).) In a previous paper (Ogden 1988), I have termed the psychological organization generating the most primitive state of being the autistic-contiguous position. (I have used the term position because I view this psychological organization as a developing and ongoing mode of generating experience as opposed to a 156 Thomas H. Ogden

phase of development. I regard it as having equal organizing significance to the paranoid-schizoid and depressive positions and as contributing equally powerfully to the dialectic constituting human experience.) The elaboration of this primitive organization represents an integral part of normal development through which a distinctive mode of experience is generated. This mode of organizing experience is characterized by specific types of defense, forms of object relatedness, quality of anxiety, and degree of subjectivity that I shall describe and clinically illustrate. The state of being generated by this psychological organization stands in both a diachronic and a synchronic relationship to the paranoid-schizoid and depressive positions. The autistic-contiguous position has a period of primacy earlier than that of the two psychological organizations described by Klein and yet coex- ists dialectically with the paranoid-schizoid and depressive positions from the beginning of psychological life (Ogden 1988). This primitive organization represents a pole of a dialectic and thus never exists in pure form any more than the concept of the conscious mind exists independently of the concept of the unconscious mind: each creates, preserves, and negates the other. Moreover, the delineation of the autistic-contiguous dimension of experience does not in any sense diminish the significance of the paranoid-schizoid and depressive dimensions of experience. The present paper represents an attempt to extend the concept of psychological ‘positions’ or organizations to include the most primitive aspects of human experience.

Primitive organization of experience The autistic-contiguous organization is associated with a specific mode of attributing meaning to experience in which raw sensory data are ordered by means of forming pre-symbolic connexions between sensory impressions that come to constitute bounded surfaces. It is on these surfaces that experience of self has its origins: ‘The ego [the “I”] is first and foremost a bodily ego’ (Freud 1923: 26) … ‘i.e. the ego [the “I”] is ultimately derived from bodily sensations, chiefly from those springing from the surface of the body’ (Freud 1923: 26, fn. added in 1927). I have retained the word autistic in the designation of the most primitive Downloaded by [New York University] at 03:54 14 August 2016 psychological organization despite the fact that the term is usually associated with a pathologically closed psychological system which I do not feel is characteristic of the normal autistic-contiguous mode. I have done so because I believe that pathological forms of autism involve hypertrophied versions of the types of defense, form of attribution of meaning to experience, and mode of object relatedness characterizing the normal autistic-contiguous organization. I believe the word contiguous is particularly apt in further naming this organization since, as will be discussed, the experience of surfaces touching one another is a principal medium through which connexions are made and organization achieved in this psychological mode. The word contiguous thus provides the On the concept of an autistic-contiguous position 157

necessary antithesis to the connotations of isolation and disconnectedness carried by the word autistic. It must be borne in mind throughout this paper that it is as serious an error to conceive of an infant generating experience in a predominantly autistic-contiguous mode as suffering from infantile pathological autism as it would be to conceive of an infant as a paranoid-schizophrenic when organizing experience in a paranoid-schizoid mode or suffering from clinical depression when organizing experience in a predominantly depressive mode. This primitive psychological organization under normal circumstances contributes the barely perceptible background of sensory boundedness of all subsequent subjective states. When infantile anxiety is extreme (for constitutional and/or environmental reasons) the system of defenses characterizing this mode becomes hypertrophied and rigidified leading to a wide range of forms of pathological autism (ranging from pathological infantile autism to autistic features of patients who have in other ways achieved a predominantly neurotic psychological structure (cf. S. Klein 1980; Tustin 1986a)).

The nature of sensation-dominated experience In an autistic-contiguous mode, it is experiences of sensation, particularly at the skin surface, that are the principal media for the creation of psychological meaning and the rudiments of the experience of self. Sensory-contiguity of skin surface and rhythmicity are basic to the most fundamental set of infantile object relations: the experience of the infant being held, nursed, and spoken to by the mother. These early experiences are object-related in a specific sense of the word that is related to the nature of subjectivity in the autistic-contiguous position. In previous contributions (Ogden 1986, 1988), I have discussed Klein’s concept of the depressive position as a psychological organization in which there is an interpreting subject mediating between symbol and symbolized, mediating between oneself and one’s lived experience. In a paranoid-schizoid mode, there is very little sense of a mediating, interpreting ‘I’; instead, the self is to a large extent a self-as-object, a self that only minimally experiences itself as the author of its own thoughts, feelings, sensations, and perceptions. Instead, in a paranoid- schizoid mode, the individual experiences himself as buffeted by thoughts, feelings, and sensations as if they were forces or things that simply happen. Downloaded by [New York University] at 03:54 14 August 2016 The nature of one’s relationships to one’s objects is determined to a large degree by the nature of the subjectivity (the form of ‘I-ness’) that constitutes the context for those object relations. In the autistic-contiguous position, the relationship to objects is one in which the organization of a rudimentary sense of ‘I-ness’ arises from relationships of sensory contiguity (i.e. touching) that over time generate the sense of a bounded sensory surface on which one’s experience occurs (the beginnings of the feeling of ‘a place where one lives’ (Winnicott 1971)). Examples of boundedness generated from relationships of contiguity include the sense of shape created by the impression of the infant’s skin surface when he rests his cheek against the mother’s breast; the sense of the continuity 158 Thomas H. Ogden

and predictability of shape derived from the rhythmicity and regularity of the infant’s sucking activity (in the context of a maternally provided holding environment); the rhythm of the ‘dialogue’ of cooing engaged in by mother and infant; the feeling of edgedness generated by the infant’s pressing his gums tightly on the mother’s nipple or finger. The rudimentary beginnings of subjectivity in the autistic-contiguous position must be described from the perspective of two vertices simultaneously. On the one hand, the infant and mother are one: ‘There is no such thing as an infant’ (Winnicott 1960b: 39, fn.). From this perspective the infant’s subjectivity can be thought of as being held in trust by the mother (more accurately, by the aspect of the mother-infant that an outside observer would view as the mother). At the same time, from another perspective, the infant and mother are never absolutely at one and the infant’s subjectivity in the autistic-contiguous position can be thought of as an extremely subtle, non-self-reflective sense of ‘going on being’ (Winnicott 1956b) in which sensory need is in the process of acquiring features of subjective desire (the sensory-level beginnings of a subject wishing for something). Sensory experience in an autistic-contiguous mode has a quality of rhythmicity that is becoming continuity of being; it has boundedness that is the beginning of the experience of a place where one feels, thinks and lives; it has shape, hardness, coldness, warmth, texture, etc. that are the beginnings of the qualities of who one is. Tustin (1980, 1984b) has described two types of experience with objects which constitute important means of ordering and defining experience in the autistic- contiguous position. (These means of organizing and delineating experience are secondarily enlisted in the construction of psychological defense.) The first of these forms of relatedness to objects (which again only an outside observer would recognize as a relationship to an external object) is the creation of ‘autistic shapes’ (1984).1 Shapes generated in an autistic-contiguous mode must be distinguished from what we ordinarily think of as the shape of an object. These early shapes are ‘“felt” shapes’ (Tustin 1986a: 280) arising from the experience of soft touching of surfaces which makes a sensory impression. The experience of shape in an autistic-contiguous mode does not involve the conception of the ‘object- ness’ or ‘thingness’ of that which is being felt. As Tustin (1984b) puts it, we can attempt to create for ourselves the experience of an autistic shape if we reduce the Downloaded by [New York University] at 03:54 14 August 2016 chair we are sitting on to the sensation it makes on our buttocks. From this perspective there is no sense of the chair as an object aside from the sensation that is generated. The ‘shape’ of that impression is idiosyncratic to each of us and changes as we shift in our seats. For the infant, the objects generating shapes in an autistic-contiguous mode include the soft parts of his own body and the body of the mother as well as soft bodily substances (including saliva, urine, and feces). Experiences of shape in an autistic-contiguous mode contribute to the sense of cohesion of self and also the experience of perception of what is becoming the object. Much later in development, words like ‘comfort’, ‘soothing’, safety’, ‘connectedness’, ‘holding’, On the concept of an autistic-contiguous position 159

‘cuddling’, and ‘gentleness’ will be attached to the experience of shapes in an autistic-contiguous mode. A second form of very early definition of sensory experience described by Tustin (1980), the experience of ‘autistic objects’, stands in marked contrast to the experience of autistic shapes. An autistic object is the experience of a hard, angular sensory surface that is created when an object is pressed hard against the infant’s skin. In this form of experience, the individual experiences his surface (which in a sense is all there is of him) as a hard crust or armour that protects him against unspeakable dangers that only later will be given names. An autistic object is a safety-generating sensory impression of edgedness that defines, delineates, and protects one’s otherwise exposed and vulnerable surface shell. As experience is increasingly generated in paranoid-schizoid and depressive modes, words like ‘armour’, ‘shell’, ‘crust’, ‘danger’, ‘attack’, ‘separateness’, ‘otherness’, ‘invasion’, ‘rigidity’, ‘impenetrability’, ‘repulsion’, are attached to the quality of sensory impressions created by autistic objects. I worked for many years in intensive psychotherapy with a congenitally blind schizophrenic adolescent named Robert (see Ogden 1982a for an extended discussion of this case). In the initial years of this work, which began when the patient was 19, he spoke very little. The patient said that he was terrified of the millions of spiders that were all over the floor, his food, and his body. He felt that they were crawling in and out of all of his bodily openings including his eyes, mouth, ears, nose, anus, and penis as well as the pores of his skin. He would sit in my office trembling with his eyes rolled back into their sockets so that only his sclerae were visible. According to the history given by the patient’s parents, siblings, and other rela- tives, Robert’s mother’s handling of him as an infant was characterized by unpredictable shifts from smothering over-involvement to extremes of hatred for this child. He was left alone in a mobile crib for hours. Robert would stand up in the crib, holding on to the bar forming its upper edge and would propel himself around the room by rhythmically banging his head against the bar. His mother told me that he seemed oblivious to the pain and that she was horrified by his ‘demoniacal wilfulness’. In the period of treatment that I will be focusing upon here, Robert refused to bathe despite every act of prodding, cajoling, bribing, and threatening that Downloaded by [New York University] at 03:54 14 August 2016 the nursing staff could devise. (Robert was hospitalized for the initial year of treatment.) He rarely changed his clothes even to sleep. His hair was a mass of greasy clumps. Robert developed an intense bodily odor that silently accompanied him and which lingered after him for hours following his departure from my office. He would lie back in the soft chair in my consulting room with his greasy hair on the hard, padded back of the chair. The aspect of the transference-countertransference interaction that I was most aware of at the time was the way in which I felt invaded by this patient. When he left my office, I could not feel that I had a respite from him. I felt as if he had managed, in a literal way, to get inside me 160 Thomas H. Ogden

(to get under my skin) by means of his odor that was saturating my furniture (with which I had become closely identified). I eventually understood these feelings as my response to (unconscious participation in) a projective identification in which the patient was engendering in me his own feelings of being painfully and unwill- ingly infiltrated by his internal object mother. In retrospect I feel that I did not give sufficient weight to an aspect of the experience to which the patient was unconsciously directing my attention. When I asked Robert what it was about showering that most frightened him, he said, ‘the drain.’ I now feel that I understand in a fuller way than I did at the time that Robert was terrified of dissolving and literally going down the drain. He attempted to ground himself in the sensation of his own distinct bodily odor which was of particular importance to him in the absence of the capacity to form well-defined visual images. His odor constituted a comforting autistic shape that helped him to create a place in which he could feel (through his bodily sensations) that he existed. His trembling gave him a heightened sense of his skin; his rolling of his eyes back into the vault of his skull insulated him from the blurred, edgeless shadows that he perceived visually. (Years later he told me that these shadows were ‘worse than seeing nothing at all’ because they made him feel as if he were drowning.) The patient’s insistence on holding his head against the back edge of my chair served to provide some degree of boundedness for him. In childhood, Robert similarly had desperately attempted to repair a failing sense of cohesiveness of self through his banging of his head against the hard edge of his crib in response to the disintegrative effect of long periods of disconnectedness from his mother. This early ‘relationship’ to hardness represents a form of pathological use of an autistic object as a substitute for a healing relationship with an actual person. The rhythmic component of the head banging and motion of the crib can be viewed as an effort at self-soothing through the use of an autistic shape. From this perspective, Robert’s insistence on not bathing is more fully under- standable. The loss of his odor would have been equivalent to the loss of himself. His odor provided the rudiments of being someone (someone who had a particular odor), being somewhere (somewhere in which he could perceive his odor), and being something for another person (a person who could smell him, be infused by him, and remember him). The use of odor as an autistic shape can in Downloaded by [New York University] at 03:54 14 August 2016 this case be viewed as non-pathological to the extent that it existed as a part of the transference-countertransference relationship that was to a large degree aimed at the establishment of an object relationship of contiguity (the ‘touch’ of odor) and was not simply an effort at creating a substitute for the object.

Autistic-contiguous experience and pathological autism Although pathological autism can be thought of as constituting an ‘asymbolic’ realm, the normal autistic-contiguous mode is ‘pre-symbolic’ in that the sensory-based units On the concept of an autistic-contiguous position 161

of experience being organized are preparatory for the creation of symbols mediated by experience of transitional phenomena (Winnicott 1951). The developmental directionality of this process stands in contrast to the static nature of asymbolic experience in pathological autism wherein the effort is to maintain a perfectly insulated closed system (in which sensory experience does not lead anywhere except back to itself). Pathological autism aims at the absolute elimination of the unknown and the unpredictable. The machine-like predictability of experiences with pathological autistic shapes and objects substitutes for experiences with inevitably imperfect and not entirely predictable human beings. No person can compete with the capacity of never-changing autistic shapes and objects to provide absolutely reliable comfort and protection. Experience at the skin surface is critically important in that it constitutes an arena where there is a convergence of the infant’s idiosyncratic, pre-symbolic world of sensory impressions and the interpersonal world made up of objects (which an outside observer would view as) having an existence separate from the infant and outside of his omnipotent control. It is on this stage that the infant will either elaborate a way of being in the world in relation to the mother and the rest of the object world or will elaborate sensory-dominated ways of being (more accurately a way of not-being) that are designed to insulate a potential self (that never comes into being) from all that lies outside of his sensory-dominated world. To the extent that the bodily system is closed off from mutually transforming experiences with human beings, there is an absence of ‘potential space’ (Winnicott 1971; see also Odgen 1985, 1987) between oneself and the other (a potential psychological space between self-experience and sensory perception). This closed, bodily world is a world without room in which to create a distinction between symbol and symbolized and therefore a world in which there is no possibility for the coming into being of an interpreting subject; it is a world in which there is no psychological space between the infant and mother in which transitional phenomena might be created/discovered. The syndrome of pathological infantile rumination is paradigmatic of the self- enclosed circularity of the pathological autistic process:

Rumination or merycism … [is] the active bringing into the mouth of swal- Downloaded by [New York University] at 03:54 14 August 2016 lowed food which has already reached the stomach and which may have started to undergo the process of digestion … The food may be partially res- wallowed, partially lost, with serious consequences for the infant’s nutrition. Unlike regurgitation, where the food runs out of the infant’s mouth without any effort, in rumination there are complex and purposeful preparatory movements particularly of the tongue and of the abdominal muscles. In some cases the hard palate is stimulated by fingers in the mouth. When the efforts become successful and the milk appears on the back of the pharynx, the child’s face is pervaded by an ecstatic expression. (Gaddini and Gaddini 1959: 166) 162 Thomas H. Ogden

In infantile rumination, the beginnings of awareness of otherness (through the feeding interaction) is short-circuited by the infant’s appropriating to himself the entire feeding situation and then engaging in a tightly closed autosensory cycle of creating his food (more accurately, creating his autistic shapes). These autistic shapes then substitute for the mother, thus transforming the feeding experience from an avenue toward increasingly mature object relatedness to a pathway to objectless ‘self-sufficiency’ (in which there is no self). In the analytic setting, one form of the equivalent of merycism can be seen in patients who take the analysis into themselves. Instead of internalizing an analytic space in which one thinks and feels one’s thoughts, feelings and sensations, such patients present a caricature of analysis in which rumination and imitation substitute for an analytic process. The analyst’s role has been entirely co-opted. Such patients often present the unconscious phantasy of having ‘raised themselves’ by taking into themselves the functions of parent and child, thus replacing genuine object relatedness with an inner world of phantasized object relations and experiences with autistic shapes and objects.

Mrs M., a 62-year-old widow, whom I saw in intensive psychotherapy for eight years, had originally been referred to me by her internist after a suicide attempt. She had used a razor to carefully make deep incisions across her wrists, arms, legs, and ankles. She then got into a tub filled with warm water and patiently waited for over three hours to bleed to death. After lapsing into a coma, she was discovered by a cleaning lady. While waiting to die, she felt the relief of the end of decades of oppressive obsessive-compulsive rituals. Mrs M., speaking in clipped sentences and almost exclusively in response to direct questions, told me that she would stand for hours in front of one or the other of the doors in her apartment before she would allow herself to go through it while she attempted to ‘get a thought right’. ‘Getting a thought right’ involved perfectly recreating for herself in her mind some experience from her past including all of its sensory features. For years (including the initial years of the therapy), this effort was focused on an attempt to re- experience the taste of the first sip of a cold glass of wine that the patient had tasted early in the relationship with her husband some 38 years earlier. She could not allow herself to open the door of her apartment to go into the next Downloaded by [New York University] at 03:54 14 August 2016 room or out into the hallway until she had successfully completed this task. She compared getting a thought right to having an orgasm; it was a fitting together of different sensations and rhythms in a very specific way. For years, such obsessive-compulsive activity filled virtually every moment of Mrs M.’s life. The symptom was understood in the course of the therapy as providing a form of comfort that was both nightmarishly tyrannizing and yet life-sustaining. The patient was terrified of disruption of bodily rhythms, particularly her breathing. During her obsessional marathons, Mrs M. felt terrified of suffocating and felt that she would not be able to resume breathing normally until On the concept of an autistic-contiguous position 163

she ‘got the thought right’. In the meantime, she felt that she had to take over the process of breathing with conscious control and could never feel that her breathing was natural, automatic, and sufficient. She was convinced that if she forgot to breathe she would suffocate. Although Mrs M. highly valued the therapy and was never late for her daily meetings with me, she found it extremely painful when I spoke because this interfered with her ability to concentrate. The experience of being with this patient was quite different from that of being with a silent patient for whom one feels one is providing a ‘holding environment’ (Winnicott 1960b). Instead, I generally felt useless. Mrs M. could and did ruminate at home in precisely the way she was doing with me. If anything, I seemed to make things worse for her by placing an additional demand on her – the demand that she felt from me to be acknowledged and made use of as a human being and as a therapist. I said to her in small bits in the second year of our work that I assumed that my own wishes to be experienced by her as human were a reflection of an aspect of herself, but that she did not at the moment feel that she could afford this complicated luxury since she was so fully involved in fighting for her life. She would look at me and nod as if to say, ‘I understand what you said, but I’m too busy to talk now,’ and then would continue with her task. Occasionally, she would breathe a sigh of relief, glance at me, nod her head, and smile in a joyless way, saying, ‘I got it right.’ She would then seem to relax and stare at me as if she were coming out of anaesthesia and looking to see who it was that had been with her during her ordeal. She would then begin to brace herself for the inevitable recurrence of the need to chase another thought so that even these interim periods were far from relaxed. Mrs M. was able to offer fragments of history during the brief periods of respite before becoming fully re-immersed in the rumination. I learned that she had deeply loved and admired her husband, a professor twenty years her senior, and that they had lived very happily together during their 22 years of marriage. It was eight years after his death that the patient attempted suicide. Dr and Mrs M. had had a large photograph collection of their lives together which the patient impulsively threw out after Dr M. died ‘because it was too much at loose ends to pack.’ (It pained me to hear her tell me this since it felt Downloaded by [New York University] at 03:54 14 August 2016 as if she had brutally sliced out a terribly important part of herself in this impulsive act.) Mrs M. saved only one picture from that collection, a photo of herself and her husband with a ‘real lion’ in which her husband was holding his hand between the lion’s open jaws. Mrs M.’s mother had been a psychotic actress who believed that she could read the patient’s mind and knew what the patient was thinking better than the patient did. Mrs M. as a child was used as a prop in her mother’s delusional dramas. The patient kept important trinkets and ticket stubs in a Chinese box given to her by her grandmother. In a fit of rage about the secretive nature of this child, the patient’s mother (when the patient was ten years old) threw the 164 Thomas H. Ogden

box away while the patient was at school. When she told me this I said that I thought I finally was beginning to understand something of the meaning of her throwing her photographs away: one’s most precious possessions are only safe if they are inside of you. Over time, I realized that this interpretation was incomplete in an important way. Mrs M. often had practically no sense of having an internal space within which to keep anything. She told me, ‘I have no insides. I had a hys- terectomy when I was 45.’ I later said to her that I thought that when she felt that she had no safe place in her to keep the people and things that were most important to her, she felt that she had to find a way to freeze time. ‘Getting a thought right’ about the taste of the wine was not an attempt to remember something. To remember would be much too painful because she would then know that the moment was over. It was there and then. I said she gave me the feeling that she was attempting to become timeless and placeless – she could enter the sensation, the taste, and become it. Everything would be there that she needed. It was only there that she could relax. (The photograph of her husband holding his hand between the lion’s open jaws must also have captured for Mrs M. a feeling that time could really be frozen.) Mrs M.’s ruminative symptoms had not begun with her husband’s death. From adolescence and before she had devoted her life to endless attempts at living in a realm of timeless sensations. In the therapy, I initially attempted to understand the meaning of the choice of each sensation, but over time I realized that this patient’s psychological world was not composed of accretions of meaning; rather, she lived in a world of timeless sensory experience that was neither internal nor external. The ruminative activity was the essence of unchanging, pure sensation. In the course of eight years of therapy, Mrs M. began to be able to live for extended periods of time in a state of mind relatively free of her obsessive ruminations. While this was occurring, I increasingly felt that I was perceiving the faint glimmer of a living human being in the room with me. At times I saw brief glimpses of a little girl capable of some joy as Mrs M. laughed about some humourous event in her life with her husband or about something I had said that she found funny. It was with a mixture of sadness and a vicar- Downloaded by [New York University] at 03:54 14 August 2016 ious sense of relief that I received a phone call that I had been half-expecting from the moment I met Mrs M.: she had been brought to the hospital after a massive stroke and had died soon afterwards.

I view the autistic-contiguous mode as an important dimension of all obsessive- compulsive defenses and believe that these defenses always entail the construction of a tightly ordered sensory containment of experience that is never simply a symbolic, ideational ordering of experience designed to ward off, control, and express conflicted unconscious anal-erotic wishes and fears. This form of defense regularly serves to plug sensorially experienced holes in the individual’s sense of On the concept of an autistic-contiguous position 165

self through which the patient fears and feels (in the most concrete sensory way) that not only ideas, but actual bodily contents will leak. Obsessive-compulsive symptoms and defenses have their origins in the infant’s earliest efforts at ordering and creating a sense of boundedness for his sensory experience. Very early on, such efforts at organization and definition come to be utilized in the service of warding off anxiety related to the disruption of the sensory-dominated, rudimentary sense of self.

The nature of autistic-contiguous anxiety Each of the three basic psychological organizations (the autistic-contiguous, the paranoid-schizoid, and the depressive) has associated with it its own characteristic form of anxiety. In each case, the nature of the anxiety is related to the experience of disconnectedness (disintegration) within that mode of experience, whether it be the disruption of whole object relations in the depressive position, the fragmentation of parts of self and object in the paranoid-schizoid position, or the disruption of sensory cohesion and boundedness in the autistic-contiguous position. Depressive anxiety involves the fear that one has in fact or in phantasy harmed or driven away a person whom one loves; anxiety in a paranoid-schizoid mode is at core a sense of impending annihilation which is experienced in the form of fragmenting attacks on the self and one’s objects; autistic-contiguous anxiety involves the experience of impending disintegration of one’s sensory surface or one’s ‘rhythm of safety’ (Tustin 1986), resulting in the feeling of leaking, dissolving, disappearing, or falling into shapeless unbounded space (cf. Bick 1968; Rosenfeld 1984). Common manifestations of autistic-contiguous anxiety include terrifying feelings that one is rotting; the sensation that one’s sphincters and other means of containing bodily contents are failing and one’s saliva, tears, urine, feces, blood, menstrual fluids, etc. are leaking; fear that one is falling, for example anxiety connected with falling asleep for fear that one will fall into endless, shapeless space. Patients experiencing this form of insomnia often attempt to relieve their anxiety (their fear of ‘falling asleep’) by tightly surrounding themselves in blan- kets and pillows, keeping bright lights on in their bedroom or by playing familiar Downloaded by [New York University] at 03:54 14 August 2016 music all night.

Ms K., a 25-year-old graduate student, began therapy because of her terror of the fog and of the sound of the ocean. The fog was frighteningly suffocating: ‘You can’t see the horizon.’ The patient was terrified of ‘going crazy’ without being aware that it was happening and frequently beseeched the therapist to inform her if the therapist should sense that the patient was losing touch with reality. Ms K.’s mother contracted spinal meningitis when the patient was four months old and was hospitalized for 14 months. From the time that the 166 Thomas H. Ogden

patient’s mother returned home, Mrs K. was confined to a wheelchair and tyrannically ruled the house from her metal chair. The patient’s earliest memory (which seemed to her as much like a dream as a memory) was of reaching out to her mother in her wheelchair and being pushed away by her mother. At the same moment, the patient, in this memory, looked out of the window and saw a small child falling through the ice on the pond that was located just behind the patient’s house. Mrs K. said, ‘You’d better go save her.’ I view this ‘memory’ as a vivid representation of the patient’s experience of falling through the containing surface of self (initially created in the interaction of mother and infant). Ms K. is both the small child falling through the ice and the older child who must try to pull the child out of the hole before she drowns. The metallic, wheelchair-mother is not felt to be capable of saving the child and in fact seems to be the one who is unconsciously being blamed for the child’s fall through the hole (the mother’s pushing the patient away). The ocean and the fog came to be experienced by Ms K. as the ever- present danger of annihilating shapelessness into which she might fall. Because of the tenuousness of the patient’s sense of cohesiveness of self, she lived in constant fear of ‘going crazy’ (losing ‘touch’ with reality in a literal, sensory way). The patient lacked the feeling of sensory groundedness that is ordinarily provided by the interpersonal ‘touch’ of common sense (a shared sensory experience of the world) which heavily contributes to our sense of being sane.

Autistic-contiguous modes of defense Defenses generated in an autistic-contiguous mode are directed at the re- establishment of continuity of the bounded sensory surface and ordered rhythmicity upon which the early integrity of self rests. Within the analytic hour, patients spanning the full range of psychological maturity commonly attempt to reconsti- tute a sensory ‘floor’ (Grotstein 1987) of experience by means of activities like hair twirling, foot tapping (even while lying on the couch), stroking of the lips, cheek, or ear lobe, humming, intoning, picturing or repeating series of numbers, Downloaded by [New York University] at 03:54 14 August 2016 focusing on symmetrical geometric shapes on the ceiling or wall, or using a finger to trace shapes on the wall next to the couch. Such activities can be thought of as self-soothing uses of autistic shapes. Between analytic hours, patients commonly attempt to maintain or re- establish a failing sense of bodily cohesion by means of rhythmic muscular activities including long periods of bicycle riding, jogging, lap swimming, etc.; eating and purging rituals; rocking (sometimes in a rocking chair); head banging (often against a pillow); riding buses and subways or driving a car for hours; maintaining a system of numbers or geometric shapes in one’s head or in computer programs that are continually being worked on (i.e. ‘perfected’), etc. On the concept of an autistic-contiguous position 167

The absolute regularity of these activities is so essential to the process of allaying anxiety that the individual cannot/will not allow any other activity to take precedence over them. Bick (1968, 1986) uses the phrase ‘second skin formation’ to describe the way in which the individual attempts to create a substitute for a deteriorating sense of the cohesiveness of skin surface. Often the individual attempts to use the sensory experience of adhering to the surface of the object in order to resurrect the integrity of his own surface. For example, one might attempt to adhere to an object by means of tenacious eye contact or a steady stream of chatter in a way that is ‘experienced … as holding the parts of the [sensory-dominated] personality together’ (Bick, 1968: 49). Meltzer (Meltzer et al.1975) has introduced the term adhesive identification to refer to the defensive adherence to the object in the service of allaying the anxiety of disintegration. Imitation and mimicry, for instance, are utilized in an effort to make use of the surface of the object as if it were one’s own. Adhesive identification is a form of identification more primitive than either introjective or projective identification in that the latter two forms of identification involve a sense of inner space into which one can project an aspect of oneself or into which one can take an aspect of the object. In an autistic-contiguous mode, one attempts to defend against the anxiety of disintegration by sticking bits of the surface of the object to one’s own failing surface. Tustin (1986a) correctly points out that the object utilized in ‘adhesive identification’ is not experienced as a separate object and therefore the term adhesive equation better describes the way in which the individual is equated with (becomes the qualities of) the surface of the object being used in this form of defense.

Mrs R., in a regressed phase of her analysis, would spend hours at a time picking at her face. She suffered from severe insomnia in large part due to fear of nightmares that she could not recall. Over time, her face became covered with scabs at which she picked. As this ‘picking’ was occurring in the analytic hours, the patient was clearly in a painfully anxious state although she said that she had ‘absolutely no thoughts.’ Mrs R. took bits of tissue from the Kleenex box next to the couch and stuck them to the lesions she was creating on her face. (She would also take Downloaded by [New York University] at 03:54 14 August 2016 extra pieces of these tissues home with her at the end of the hour.) It did not seem to me that either self-destructive wishes or displaced hostility towards me were the core of this activity at this point in the analysis. I said to her that I thought she must feel as if she were without skin; she did not sleep because when she was asleep she must feel psychologically defenseless to the danger of nightmares. I told her that I could understand her attempt to cover herself with my skin (tissues) since this seemed to make her feel a little less raw. In the hour following this intervention, Mrs R. fell asleep and slept for almost the entire session until I woke her to tell her that our time was up. 168 Thomas H. Ogden

In the next meeting, the patient said that even though she had not had a blanket while sleeping in my office, she had the distinct feeling when recalling that session that she had been sleeping under some sort of cover. Mrs R.’s capacity to sleep during her session represented an expanded and more fully symbolic use of me as a second skin. She utilized me and the analytic setting as a symbolic and yet tangibly felt medium in which to wrap herself. She felt sufficiently covered and held together to safely sleep.

Before concluding this section, I would like to mention briefly two forms of symptomatology where the concept of autistic-contiguous modes of defense must supplement understandings formulated in terms of defenses erected in the face of anxiety resulting from conflicted sexual and aggressive wishes. First, compulsive masturbation often serves the purpose of creating a heightened experience of a sensory surface in order to ward off feelings of loss of sensory cohesion. A female patient would masturbate for hours each day without conscious sexual phantasy. Orgasm was not the goal. When orgasm did occur, it was experienced as an unwelcome ‘anticlimax’ which ended the only part of the patient’s day during which she felt ‘alive and in one piece’. Secondly, painful, anxiety-producing procrastination also often serves the purpose of generating a palpable sensory edge against which the patient attempts to define himself. The ‘deadline’ is elevated to the position of a continually felt pressure in the patient’s emotional life that can be a felt presence at every moment whether or not the patient is consciously focused upon it. These patients describe the anxiety of the approaching deadline as a pressure that they hate and at the same time continually seem to create for themselves: ‘A due date is something to push up against like a wall in front of me.’ A deadline that is finally met usually does not produce more than a sense of momentary relief and instead often throws the patient into a state of panic. Very frequently such patients become physically ill once the task has been completed (usually at the last possible moment prior to the deadline), experiencing such symptoms as migraine headaches, dermatitis, or somatic delusions. Such symptoms can be understood as substitute efforts at maintaining a sensory surface in the absence of the containing pressure of the deadline. Downloaded by [New York University] at 03:54 14 August 2016

‘Internalization’ in the autistic-contiguous position As mentioned above, in a psychological field in which the individual has little if any sense of internal space, the concept of internalization becomes virtually meaningless, especially when the idea of internalization (including identification and introjection) is linked to the notion of conscious and unconscious phantasies of taking parts or all of another person into oneself. Nonetheless there is psychological change arising from experience with external objects in an autistic- contiguous mode and such change is mediated in part by the process of imitation. On the concept of an autistic-contiguous position 169

In autistic-contiguous forms of imitation, the individual experiences a change in the shape of his surface as a result of the influence of his relations with external objects. At times, imitation is one of the few ways the individual has of holding on to attributes of the object in the absence of the experience of having an inner space in which the other person’s qualities or parts can in phantasy be stored. Since in an autistic-contiguous mode the feeling and phantasy of being entered is synonymous with being torn or punctured, imitation allows the influence of the other to be carried on one’s surface. In pathological autism this sometimes manifests itself as echolalia or as an endless repetition of a phrase or a word uttered by another person (cf. Gaddini 1969). Imitation as a method of achieving a degree of cohesiveness of self must be distinguished from Winnicott’s (1960a) concept of a False Self personality organization. There is nothing false about autistic-contiguous imitation in that it does not stand in contrast to, or serve to disguise or protect, something truer or more genuine within: there is no within or without. In an autistic-contiguous mode, one is one’s surface and therefore the act of imitation is an effort at becoming or repairing a cohesive surface on which a locus of self can develop. Imitation not only serves as a form of perception, defense, and way of ‘holding on to’ (being shaped by) the other, it also serves as an important form of object relatedness in an autistic-contiguous mode. In a previous paper (1980), I described aspects of my work with a hospitalized chronic schizophrenic patient who for years lived in a world so stripped of meaning that people and things were treated by him as completely interchangeable. Phil seemed psychologically dead as he lay on the floor of my office or was escorted from one hospital ‘activity’ to another. The initial form of contact that he made with me in the therapy was by imitating my posture, my tone of voice, my every gesture, every word I spoke, and every facial expression I made. Rather than celebrating this as his entry into the land of the living, this felt to me at the time like an attack on my ability to be alive. I felt as if my spontaneity were being tyrannically drained out of me. Nothing I did felt natural. At that time I understood this as a form of projective identification (cf. Ogden 1979, 1982b, 1983) in which the patient was engendering in me (communicating to me) his own feelings of lifelessness and incapacity for spontaneity or for being alive in any way. However, I did not at the time sufficiently understand the Downloaded by [New York University] at 03:54 14 August 2016 phenomena that I am referring to here as autistic-contiguous to appreciate the nature of the affection in the patient’s imitation of me. He was using me as a second skin or container within which he was experimenting in a primitive way with what it might feel like to be alive. He was paying me a very great compli- ment indeed by indicating that it was to be my skin in which he would conduct this experiment. Imitation in an autistic-contiguous mode is by no means restricted to patients suffering from pathological childhood autism, borderline conditions and schizophrenia. It is very common for a therapist early in training to attempt to imitate his supervisors or his own therapist in an attempt to hide from himself the absence 170 Thomas H. Ogden

of his own identity as a therapist. One such therapist described this experience as ‘using the skin of the supervisor’ when he was with his patients. This ‘skin’ was felt to be ‘stripped off’ when a second supervisor was critical of this student’s work leading the trainee to feel painfully ‘raw.’ He would then immediately attempt to ‘take on the skin of the second supervisor’. In therapy, this patient imitated his own patients by presenting their difficulties as his own, thus defend- ing against awareness of the feeling that he did not have a voice of his own with which to speak. Instead, the patient desperately attempted to get the therapist to make interpretations and give advice which would serve as substitutes for the patient’s own thoughts and feelings as well as a substitute for a voice which he could feel was his own.

Autistic-contiguous anxiety and the binding power of symbols It must be borne in mind throughout this paper that an autistic-contiguous mode of experience does not exist in pure form any more than one encounters paranoid-schizoid or depressive modes in pure form. Each of these modes represents a pole of a dialectical process between which experience is generated. The autistic-contiguous mode can be thought of as contributing a sense of boundedness of sensory experience which serves to generate the sensory ‘floor’ (Grotstein 1987) of all experience. The paranoid-schizoid mode provides a good measure of the immediacy and vitality of lived (concretely symbolized) experience. The depressive mode is a principal medium through which experience is endowed with qualities of subjectivity, historicity, and the richness of layered symbolic meanings. Psychopathology can be thought of as a collapse of the generative dialectical interplay of modes of experience (cf. Ogden 1985, 1987). Collapse in the direction of an autistic-contiguous mode results in a tyrannizing imprisonment in a closed system of bodily sensations that precludes the development of ‘potential space’ (Winnicott 1971). Collapse in the direction of a paranoid-schizoid mode results in a sense of entrapment in a world of things-in-themselves wherein one does not experience oneself as the author of one’s thoughts and feelings; rather,

Downloaded by [New York University] at 03:54 14 August 2016 thoughts, feelings, and sensations are experienced as objects or forces bombard- ing, entering into, or propelled from oneself. Collapse in the direction of a depressive mode results in the experience of a subject alienated from his bodily sensations and from the immediacy and spontaneity of lived experience. A discussion of the diversity and complexity of the dialectical interplay of the depressive, the paranoid-schizoid and the autistic-contiguous modes was begun in a previous paper (Ogden 1988). I would like to make some additional comments here about an aspect of this interplay of modes. There is a form of interpenetration of autistic-contiguous and depressive modes through which the sensory boundedness of the autistic-contiguous position and the capacity for On the concept of an autistic-contiguous position 171

symbol formation, historicity, and subjectivity of the depressive position together contribute to the creation of a whole that is larger than the sum of its parts. In the absence of this mutually generative interplay, specific forms of psychopathology are generated upon which I would like to focus. Disconnectedness of the depressive mode from the autistic-contiguous mode leads to psychological states in which the individual becomes either alienated from or entrapped in sensory experience. In the former, the individual defensively attempts to use ideas, words, and other forms of symbol formation proper (Segal 1957) as substitutes for an internal sensory groundedness in sensation-dominated experience.

Mr D., an extremely bright graduate student in philosophy, began analysis at the age of 25 saying that he did not know what it meant to feel sexual desire. He had of course heard other people use words to describe such feelings, but he did not know from his own experience what it felt like to be sexually excited. He could with effort spend time with and converse with fellow students of both sexes, but he did not feel that anything he did was ‘natural’; in fact nothing in his life felt natural with the exception of kayaking during which he could completely relax and ‘flow with the river’ in an unselfconscious way. In this case, neither the autistic-contiguous mode nor the depressive mode was absent, but each had become disconnected from the other. Mr D. perpetually felt like a visitor. Being in an airplane was one of the few places he could relax because he knew he did not fit in the place he had left and he knew he would not fit in the place to which he was going, but at least for the duration of the flight he felt less painfully out of place. It is only in the generative interplay of the autistic-contiguous and the depressive modes of generating experience that one creates the feeling that one has a place of one’s own in the ‘order of things’ and can do things in a way that feels natural. In the case of Mr D., the collapse of the dialectical interplay of the autistic- contiguous and the depressive modes in the direction of the depressive led to a rigidly defensive and impoverished psychological state that might be

Downloaded by [New York University] at 03:54 14 August 2016 thought of as a schizoid state (Fairbairn 1940) or a ‘disaffected state’ (McDougall 1984). Perhaps Mr D.’s psychological state might be best described as a ‘de-sensate state’.

The dialectic of the autistic-contiguous and the depressive modes of generating experience may also collapse in the direction of the autistic-contiguous leading to a feeling of entrapment in a world of sensation that is almost completely unmediated and undefined by symbols. Many years ago, I inadvertently stumbled upon a way of creating for oneself this type of disconnexion of the autistic-contiguous mode from the depressive mode. After dinner one night, while still sitting at the 172 Thomas H. Ogden

dining-room table, it suddenly occurred to me how strange it was that the thing called a napkin was named by the elision of the sounds ‘nap’ and ‘kin.’ I repeated the two sounds over and over until I began to get the very frightening feeling that these sounds had no connexion at all with this thing that I was looking at. I could not get these sounds to naturally ‘mean’ the thing that they had meant only minutes before. The link was broken and to my horror could not simply be mended by an act of will. I imagined that I could, if I chose to, destroy the power of any and all words to ‘mean’ something if I thought about them one at a time in this way. At that point, I had the very disturbing feeling that I had discovered a way to drive myself crazy. I imagined that all things in the world would feel as disconnected as the napkin had become now that it had been disconnected from the word that is used to name it. Further, I felt that I could become utterly disconnected from the rest of the world because all other people would still share in a ‘natural’ (i.e. a still meaningful) system of words. Such is the nature of the beginnings of a collapse of the dialectic of experience in the direction of sensation- dominated experience that is unmediated symbolically. It took some years before the word ‘napkin’ re-entered my vocabulary in a fully unselfconscious way. The fact that one’s experience of self is powerfully rooted in the dialectical interplay of the sensory and the symbolic is often highly visible in psychoanalytic work with teachers and students of linguistics. These patients often experience anxiety states bordering on panic in association with the feeling that they are dissolving as they dismantle the binding power of language. This has in each case that I have encountered led to the patient’s need to leave the field of linguistics at least temporarily.

Summary The development of British object-relations theory over the past twenty years can be viewed as containing the beginnings of an exploration of a realm of experience that lies outside of the states of being addressed by Klein, Winnicott, Fairbairn, and Bion. In this paper, the idea of an autistic-contiguous position is proposed as a way of conceptualizing a psychological organization more primitive than either the paranoid-schizoid or the depressive position. This mode of organizing experience stands in a dialectical relationship to the Downloaded by [New York University] at 03:54 14 August 2016 paranoid-schizoid and depressive modes: each creates, preserves, and negates the others. The autistic-contiguous mode is a sensory-dominated, pre-symbolic mode of generating experience which provides a good measure of the boundedness of human experience and the beginnings of a sense of the place where one’s experience occurs. Anxiety in this mode consists of an unspeakable terror of the dissolution of boundedness, resulting in feelings of leaking, falling, or dissolving into endless, shapeless space. Principal forms of defense, ways of organizing and defining experience, types of relatedness to objects, and avenues to psychological change in the autistic-contiguous position are discussed and clinically illustrated. On the concept of an autistic-contiguous position 173

Note 1. Tustin (1980, 1984b), following the lead of Anthony (1958), conceived of a phase of ‘normal autism’ (which she more recently has designated the ‘auto-sensuous’ (1986a) phase of development). In this phase, the infant makes use of ‘shapes’ in a way that resembles the ‘shapes’ utilized by autistic children; however, the normal infantile utilization of shapes is not nearly as extensive or rigid and does not serve to cut off relations with external objects as is the case in pathological autism. Downloaded by [New York University] at 03:54 14 August 2016 Chapter 12 Trying to enter the long black branches Some technical extensions for the analysis of autistic states in adults1

Judith L. Mitrani

Never to enter the sea and notice how the water divides With perfect courtesy, to let you in! Never to lie down on the grass, as though you were the grass! Never to leap in the air as you open your wings over The dark acorn of your heart! No wonder we hear, in your mournful voice, the complaint That something is missing from your life! (Oliver 1997: 61)

The title of this chapter borrows from the title of a poem by Mary Oliver (1997). The epigraph of this chapter, quoted from that same poem, seems apposite to many patients who find their way to the analytic couch. These patients leave the impression that they are in search of something missing in their lives: perhaps the emotional contact with an elemental quality of self, a certain kind of lived-experience akin to entering a courteous sea, being one with the grass, leaping in the air and even opening to the dark acorn of the heart. These missing elements of experience, linked to various unlived and heretofore unheard aspects of self and their ‘uncontained’ (in Bion’s sense of the term2) perceptions of encounters with the agony and ecstasy of being, often come to inhabit a hidden capsule3 within many ordinary neurotic, borderline or psychotic adults (Bion 1957; S. Klein 1980; Mitrani 1992; Rosenfeld 1985; Steiner 1993; Tustin 1986a). This capsule may be shrouded in somatic symptoms, encased in Downloaded by [New York University] at 03:54 14 August 2016 extremes of acting out, ensconced in therapeutic enactment or overlaid with a verbal message that is, by and large, deceptive in its expression. Nonetheless, as disturbing, misleading and distracting as these protective decoys may at times be for the analyst hard at work trying to enter ‘the long black branches of other people’s lives’ (Oliver 1997: 61) – we frequently discover that their effect upon us (if we can bear to suffer it) is imbued with meaningful-if-encrypted communications, perhaps signaling a point at which that ‘something missing’ might have the opportunity to emerge and to develop. The implications of the findings of Frances Tustin and this author’s technical extensions and applications of those findings to the analytic work within these Technical extensions for analysis of autistic states in adults 175

obscure areas of the lives of ‘ordinary adults’ is the subject of this chapter. Throughout, I will demonstrate some of the ways in which Tustin’s innovations have and are continuing to open up new possibilities for deepening the analyst’s comprehension of those persons in whom unmentalized happenings (Mitrani 1994) have been silently encapsulated through the use of autosensual maneuvers (Mitrani 1992). I hope to be able to convey that, although these encapsulations constitute daunting obstacles to emotional and intellectual development, are consequential in both the relational and vocational spheres for many analysands, and present unending challenges for analysts, it is possible to detect and to modify them.4

Going forward Oliver asks, ‘Who can open the door who does not reach for the latch? Who can travel the miles who does not put one foot in front of the other, all attentive to what presents itself continually? Who will behold the inner chamber who has not observed with admiration, even with rapture, the outer stone?’ (1997: 61). When the analyst can behold the ‘inner chamber’ without sentimentality, but with an appreciation of both the nature and function of the ‘outer stone’, her own as well as her patient’s, she may be able to navigate through a certain range of therapeutic impasse and to tolerate what may at times seem like interminable frustrations when encountering patients’ ubiquitous, deeply ingrained and stony autosensual protections. To paraphrase Graham Greene (1929), the category of patient addressed in this chapter (not unlike poets and writers) has a splinter of ice in their hearts. Perhaps the analyst’s perseverance and her artful and timely delivery of hard-earned and mindful awareness may constitute a warm, therapeutic bath that can enable her to penetrate, to reach, and to melt this icy obstruction to development. By detecting and exploring this dimension of psyche-soma, the analyst may be better equipped to refine her insights, to find new ways in which to articulately decipher the plight of the infant in the adult patient, and to define her current role in the revival of this predicament in the transference. A familiarity with the concepts of autistic objects (Tustin 1980) and autistic shapes (Tustin 1984b) is helpful in this effort,5 as is our sensitivity to the existential terrors inherent in both Downloaded by [New York University] at 03:54 14 August 2016 the pre-mature awareness of two-ness and the ecstasy of at-one-ment (Tustin 1981). Tustin’s emphasis on the role of sensation – as both an integral aspect of primordial terrors and as material for the construction of the protective barrier against the awareness of such terrors – draws attention to the dimension of autosensuality and its centrality to the work within primitive mental states. With these enlightening tools in hand, the analyst may be able to avoid becoming hope- lessly lost in this dimension, where shadow and light are occluded from perception and emotional experience. Additionally, the analyst may become more capable of shepherding her analysand out of a mindless island of sameness and into a shared world, where opposites intermingle and attenuate one another, and 176 Judith L. Mitrani

the ‘rhythm of safety’ (Tustin 1986a) of the analytic frame, process, and relationship eventually take the place of the virtual ‘rocking’ and ‘head-banging’ of compulsive repetitions which are sometimes at the root of interminable analyses.

Detecting autistic states in adults In these individuals, areas of normal development exist, circumventing those traumatic happenings of infancy that could not be experienced but were instead walled-off from both conscious and unconscious awareness (S. Klein 1980; Tustin 1986a). Unlike the case of split-off and projected aspects of objects and/ or self, or repressed memories of events, it is difficult to locate these encapsulated resources merely by listening for their verbal derivatives, expressed as aspects of self, objects, and perceptions residing in other people in the day-to-day life of the patient or as they might be revealed in dreams. This may be so because, while in an autistic state, projective identification is unavailable as a means of communication (Bion 1962a) and, as with autistic children who cannot play (Tustin 1988), these patients rarely dream since, in this domain of the psyche, symbol formation is as yet undeveloped (M. Klein 1930). Because encapsulated ‘happenings’ are so well hidden – not just from the analyst but also from the patient himself – we are left to intuit the existence of these ‘buried treasures’ in order to begin to image them, and eventually to be able to explicitly recognize and acknowledge them for and to the patient. This is no mean trick, as it requires the analyst’s capacity to be aware of and to bear the awareness of what is missing, and to be able to digest that awareness so that it becomes food for thought to be shared with the patient. Along with our consideration of that which we intuit, a continual and rigorous process of ‘differential diagnosis’ – performed throughout the analytic hour, and derived from a careful and sustained observation and examination of the signs carried on the currents of the immediate transference and countertransference derivatives – is vital in order to ensure that the analyst’s interventions are usefully geared toward the patient in that moment. Accordingly, I will briefly outline some criteria to keep in mind while discriminating autistic states from those more truly object-related states. Downloaded by [New York University] at 03:54 14 August 2016 Differential diagnosis of autistic states: moment to moment First, while in an object-related state, the patient experiences the analyst either as a part of the mother’s body associated with some maternal function, or as an animated, lively whole person who is able to move about at will. In contrast, the patient in an autistic state does not experience the analyst as a real, animate, lively entity existing in a space of her own, but rather as an inanimate ‘thing’ that is made up, absorbed, exploited, manipulated, or avoided in order to secure a sensation of existence, comfort, safety, and impermeability. Technical extensions for analysis of autistic states in adults 177

Second, in an object-related state, some degree of awareness of separateness from the analyst is tolerated to a greater or lesser extent by the patient. In contrast, in an autistic state, normal ‘flickering states of awareness of otherness’ are unable to be endured. Consequently, analyst and patient remain largely undifferentiated (from the patient’s point of reference) and the resulting contact with the analyst is mainly felt on a sensuous level. In this state, the analyst is not related to, per se, but is ‘utilized’ for the sensations that she engenders upon the surface of the skin, eyes, ears, and/or the mucous membranes of the patient. These sensations serve either to distract the patient’s attention away from potentially anxiety producing happenings – providing an illusion of safety, strength, and impermeability – or they may have a numbing or tranquilizing effect, which serves to block out some insufferable awareness. Third, when the object-related state prevails, anxieties defended against (in unconscious fantasy) are either paranoid-schizoid or depressive in nature: anxieties and defenses well defined by Melanie Klein (1946). In contrast,those anxieties evaded through autosensual or adhesive maneuvers (Bick 1968) in the autistic state are more accurately conceptualized as raw and unmitigated panic equated with the elemental sensations of falling out of control, of discontinuity of being, of nothingness, dissolution, and evaporation, of being a no-body-nowhere, all terrors delineated in Tustin’s work and in the work of Winnicott (1949). Additionally, while in an object-related state, the individual engages in complex unconscious fantasies (e.g. of splitting, projective identification, and manic denial) to defend against the pain, despair and rage of envy and the awareness of helpless dependence upon the analyst. However, in the autistic state, the patient employs adhesive equation to block out the painful and life-threatening awareness of two-ness and the overwhelming ecstasy of at-one-ment. Fourth, in an object-related state, the patient’s ego oscillates either between a state of increasing integration and a state of non-defensive regression to unintegration on the one hand, or between a state of integration and a state of defensive disintegration on the other. By comparison, in an autistic state, ego or self exists and operates predominantly in an unmitigated state of passive primary unintegration (Meltzer et al. 1975.) Fifth, the nature of ‘thinking’ in the object-related state is either abstract or concrete and may be either realistic or omnipotent in nature. In contrast, in autis- Downloaded by [New York University] at 03:54 14 August 2016 tic states there is little actual mentation (Mitrani 1994). What appears to the observer as ‘thinking’ remains on the level of a reflexo-physiological reaction and ‘innate forms’6 (Tustin 1986a) prevail in the absence of symbolization, unconscious fantasy, and imagination, since transitional space (Winnicott 1951) is non-existent. Sixth, the truly object-related individual reacts to separations and losses with either expressions of anxiety, neediness, and emotional pain, or with a tight-fisted control of the aforementioned through the use of tyranny and seduction. In contrast, the individual in an autistic state reacts to the awareness of separateness with either total obliviousness or complete collapse. Consciousness of 178 Judith L. Mitrani

dependency in the object-related individual is either experienced as the need for and the act of reliance upon an analyst who is separate from the analysand, or it is defended against through forms of manic denial. In autistic states, dependency in the analysand assumes the form of a thin and tenacious clinging to the surface of an as-yet-undifferentiated analyst, felt to be part of and contiguous with the analysand. Lastly, when defenses against the awareness of separateness and loss break down in the object-related state, there is an experience of threat to the patient’s sense of omnipotence, culminating in feelings of rejection. In contrast, when omnipotence fails in the autistic state, this failure is felt as a corporeal collapse, as a dreadful sensation of being ripped off and thrown away, a bodily feeling of total and irreversible dejection. It is not an experience of the loss of the analyst or even the presence of the absence (O’Shaughnessy 1964), as it is in object- related states. One autistic child, John, called this the ‘black hole with the nasty prick’ (Tustin 1972a: 30). This ‘black hole’ is felt as an awesome force of power- lessness, of defect, of nothingness, and of ‘zero-ness’ expressed, not just as a static emptiness, but as an agonizingly implosive centripetal pull into a void.7

Those who have ‘lingered in the chambers of the sea’ It might be accurate to say that the patients addressed in this chapter have ‘lingered in the chambers of the sea’ (T. S. Eliot 1998) for much of their lives. They are unwittingly addicted to their sensation-dominated ways of surviving at the expense of experiences of ordinary human relationship. The frequency with which liquid states are evoked in the clinical material of these patients has been noteworthy (Tustin 1986a). For example, one adult patient, Jean, said that she felt like a ‘waterfall, falling out of control into nothingness’ (Tustin 1986a: 217) when she was aware of slipping out of the mindful attention of her analyst on holiday breaks. The experience of freezing in autistic states is a reaction to this terror of falling out of control when a personal sense of existence is still fluid, and when the personality and body are not yet fully differentiated or solidified (Tustin 1986a). In fact, freezing is the way in which a liquid becomes a solid body. However, Downloaded by [New York University] at 03:54 14 August 2016 when our patients freeze up in order to attain a sensation of solidity, their icy barrier often impacts others by leaving them cold. Consequently, the occurrence of healing emotional transactions is impeded. In her novel, The Lovely Bones, author Alice Sebold’s opening words express two different views of the frozen capsule of the autistic state.

Inside the snow globe on my father’s desk. There was a penguin wearing a red-and-white-striped scarf. When I was little my father would pull me into his lap and reach for the snow globe. He would turn it over, letting all the snow collect on the top, then quickly invert it. The two of us watched the Technical extensions for analysis of autistic states in adults 179

snow fall gently around the penguin. The penguin was alone in there, I thought, and I worried for him. When I told my father this, he said, ‘Don’t worry, Susie; he has a nice life. He’s trapped in a perfect world.’ (Sebold 2002: 3)

Like Susie, the analyst may be moved to feel the isolation within the perfect world of the icy sphere of autism, while the untrained or emotionally distant observer may see this world as idyllic. We know that without lively human connections, it is not possible for certain vital internal mental and physical structures to develop, and when emotional contact is interrupted, previously developed structures can whither away (Spitz and Wolf 1946). Without these durable structures, patients can suffer emotional and physical ‘meltdowns’ in the face of life’s stressors. In analysis, just as the firm, reliable, resilient, and receptive presence of the analyst is an important factor if these lasting structures are to be established, it is also important that a physical setting with similar qualities be provided.

The setting To facilitate the emergence of the infantile transference in analysis, an environment of relative safety and security needs to be maintained. Our consulting rooms are equated, in the unconscious, with the maternal body (Klein 1961). Furthermore, just as the modulation of the ups and downs of the mother’s emotional and mental state and her physicality is essential to healthy fetal development and the emergence of the baby from the womb, for adult patients the therapeutic setting and the rhythm and consistency of the work affects development, the ability to attach and to separate healthfully. In analysis, we aim to and often do penetrate our patients’ protective capsules, releasing explosive feelings of violence, overwhelming terrors, unutterable rapture and torrential grief. Thus it is essential to provide a setting capable of bearing and containing these emotions. For both analyst and analysand, frequent meetings are indispensable. As one patient expressed it, ‘I’d be crazy to be open and vulnerable when you’re only with me once a week!’ Perhaps the same can be said for the analyst who is charged with sustaining and transforming all that she Downloaded by [New York University] at 03:54 14 August 2016 has opened herself up to in a given hour. For both members of the analytic couple, prerequisites of continuity of frame, attention, listening, and interpretation are a necessary complement to the analyst’s alert and constrained attention. Within such an ambience, the patient can more readily experience both a listening and speaking object. However, when changes and alterations in the setting or schedule are unavoidable, the analyst is alert to and mindful of the consequences of such modifications and the need to be sensitive when listening for and dealing with the patient’s reactions, including those experienced/expressed in the realm of sensation, as might be seen in the following vignettes. 180 Judith L. Mitrani

Lucie Thirty-five-year old Lucie was vulnerable to the slightest variation in the setting and to any change in my person. Over a weekend prior to the week preceding a long holiday break, I had trimmed my hair. When she saw me on Monday, Lucie appeared grief stricken. Once on the couch her anguish turned to rage and she quickly clammed up. With time and encouragement, she grudgingly spat out a few telling words: ‘Your hair! How could you? You didn’t even save the cuttings for me.’ With this brusque protest, everything came to a screeching halt. Walled off in sullen silence, Lucie turned to face the wall for much of the hour. Absolutely nothing I could say to her served to re-establish contact: it felt that she had become the wall. During the silence, I was very aware of my own dread of what would become of her during my absence. I envisioned a very rocky reunion, if indeed she returned to the analysis at all. Then I began to feel that all had come to an end and feared that I was about to be abandoned. Barely overcoming a strong inclination to retreat from her rejection and in light of my fantasies of abandonment and loss, which I took as a sign of how unbearable and permanent our separation had felt to her – not a separation but an amputation, a cut – I told Lucie that I thought she might be communicating the sense that my hair-cut was a ‘her-cut’. Furthermore, I said that I thought she was letting me know that she could not bear the feeling of my thoughtlessly cutting her off along with the soft texture of our contact. Lucie turned her head slightly in my direction. I thought that this might be a sign that she could now dare to separate from the wall that protected her from the catastrophic awareness of our separateness during the break. Thus I was encouraged to say, ‘Perhaps you are also conveying how insufferable is the palpable dread that you and I might never grow back together again, especially when it feels that I cut off those soft and delicate wisps of cooperation that grew in our work together over the term and that I’ve carelessly thrown it all away.’ Lucie opened just a bit and said, ‘Yes, that’s true. And what if there’s a crash?’ As Lucie’s response seemed to let me in on an additional feature of her dilemma, I added, ‘When I hurt and enrage you so carelessly by cutting you off like that,

Downloaded by [New York University] at 03:54 14 August 2016 a terrible collision occurs, with both of us crashing and falling out of control, exploding to bits. So horrifying is this sense of us in pieces, you must turn away from me, gluing yourself to the wall for protection.’ This last intervention addressed an additional significance in Lucie’s turn toward the wall for durable comfort. It seemed to me that when her crashing emotions (provoked by my holiday leave) were felt as potentially threatening (‘And what if there’s a crash?’) to the wholesomeness of our contact, I too was momentarily experienced as ‘cut’ and broken, unreliable and even dangerous, not only when I was absent but when present in that moment as well. Perhaps moments like these, when the analyst can continue to function mindfully and non-defensively in the Technical extensions for analysis of autistic states in adults 181

face of explosive emotions (the patient’s as well as her own), the fear of coming apart, falling apart out of control can be attenuated and faith in the relationship can be restored. This moment with Lucie also demonstrates how something that may seem like an image to the analyst from the descriptions the patient articulates is instead felt as ‘a repertoire of relatively uncoordinated sensations, which are sensed rather than imaged’ (Tustin 1986a: 216). In like manner, what might appear to be fantasies or dreams are more like tactile hallucinations, and the analyst must try to make her own images explicit and present them in a language that may touch the patient in such a state of mind. Another patient, Brad, also suffered from these tactile hallucinations.

Brad Early in our work together I discovered that Brad felt physically crumpled up and thrown out at the end of the session, equating himself with the paper towel that lay on the pillow of my couch where he rested his head during the hour. He often felt that I peeled him off my body-couch or breast-pillow and that I carelessly threw him away, and he begged me to fold and to save him from time to time (Mitrani 1992). Otherwise Brad said that he felt he was always ‘starting from scratch’. I eventually came to realize that the ‘scratch’ my patient referred to was the sensation he experienced on his tender skin. His way of mastering this happening, and thus making it bearable, was to scratch the skin on his arms, legs, and face after each session, sometimes until he bled, in order to achieve a renewed sensation of rebirth and ‘there-ness’, to evade an experience of helplessness and vulnerability, and to toughen up against what he felt to be my careless treatment of him.

Audrey Audrey physically felt the impact of any shifts on my bookshelves, as though my books were parts of me that must be kept in order, always the same. She had memorized their placement, which gave her a sensation of control over me. Downloaded by [New York University] at 03:54 14 August 2016 She could put me in my place and I would stay put. However, each new addition to or subtraction from my library provoked a reaction, much like the stranger anxiety observed in babies in the latter half of the first year of life. With time we could appreciate her indelible sense of Mother’s manic-depressive moods swings, which were felt like a mother in pieces, out of control, in fragments, and out of sorts: a monster-mother who was unable to hold herself or the baby-Audrey together. This feeling pre-empted the establishment of a sense of comforting familiarity and obstructed the development of a consistent basis for trust in the other, tolerance for change, and the evolution of Audrey’s self-confidence. 182 Judith L. Mitrani

Connie A similar reaction to variations in light in my room, mainly connected to the varied times I would see her throughout the week, was a source of distress for Connie. She would often brace herself physically by holding onto the doorframe with both hands before entering my room. I learned that this change in the intensity of the light was experienced by my patient as a ‘dizzying’ and ‘disorienting shock’ that, on a sensation level, was felt as a ‘slap in the face’ or as an ‘earthquake’, a harbinger of my ‘change in mood’ or shift in my feeling for her. Connie was able to tell me that these changes were like a ‘tsunami’ that threatened to sweep her away. Such changes in the therapeutic setting may be grist for the analytic mill, and as such can be made meaningful through interpretation. However, the development of ‘a rhythm of safety’ (Tustin 1986a: 26) is, in part, established through an experience of constancy in the environment of the consulting room, as well as in the consistent functioning of the analyst as a receptacle for projections and as a reliable source of verbal understanding for the ‘grist’ brought into the therapeutic relationship by the analysand. This point brings me to the problem of patients’ idiosyncratic use (while in an autistic state) of the reliable setting provided.

The idiosyncratic use of objects Even though the analyst strives to provide a stable environment within which those in their care may come to feel safe, patients often turn the analyst and the analytic environment upside-down, in one way or another. Tustin (1980, 1984b) discovered that autistic children use ordinary objects not in the course of child’s play as a mode of communication, but for the sensations that these objects engender on the surface of their skin. Autosensuous maneuvers may also become apparent in the way that certain adult analysands use the consulting room, the objects in it – including the couch itself – and the qualities of the analyst. When the analysis is used in these idiosyncratic ways, opportunities for gaining insight into and having experiences from which to learn can be lost. I will present some examples of what I am suggesting from my work with Karen, an outwardly successful professional in her mid-thirties. Downloaded by [New York University] at 03:54 14 August 2016 Karen Throughout the first year of her analysis, no matter if the room were warm or cool, before lying down, Karen would take up the blanket that lay at the foot of the couch. While holding a corner of it in the palm of one hand, the thumb on that same hand was inserted into, sucked, and slid rhythmically in and out of Karen’s mouth. The remainder of the blanket was spread out and covered all but Karen’s toes, which she wiggled continuously whenever I spoke to her. So secretive and smooth were Karen’s undercover movements, it took many months of careful observation and listening, as well as much attention to my own Technical extensions for analysis of autistic states in adults 183

imagination, before I could make explicit the use that my patient was making of the blanket – to hide a myriad of sensation-producing activities. Under cover, Karen constantly caressed her breasts with her free hand or masturbated with her hand in her trouser pocket, activities just barely detectable under wraps from my position in the chair behind the couch. At the same time, I noticed that Karen’s negative feelings toward me were almost never expressed verbally. However, when I was aware of being somewhat off in my understanding of her, it became clear that she would begin to pinch her nipples, scratch her arms, or pick at the skin of her cuticles and tear at her finger- nails. Over time and little by little, I was able to speak to Karen about these hidden, self-inflicted wounds as well as the soothing sensations that she could reliably create for herself. We also considered how these each might serve to obliterate any awareness of helplessness, dependency, and the existence of hurt- ful otherness as well as any real experience of togetherness. The ecstasy8 of at-one-ment (Tustin 1981) can become just as terrifying as the despair evoked by separateness or abandonment. With Karen’s unconscious cooperation, I was able to ‘uncover’ the equation of the softness of the blanket with the soft musicality of my voice, further equated with the softness of Karen’s own skin and the silent and pleasurable sensations she produced during the hours. My words were rarely taken in for their meaning, but instead were more often felt as harmonious sensations that flowed over Karen’s skin and slipped in and out of her ears, not unlike the sensation of her thumb slipping in and out of her mouth in a self-controlled and self-soothing way. It became apparent that, whenever Karen repeated these gestures in the many hours of absence between the sessions and during weekends, she could obliterate the sharp distinctions between separateness and togetherness. Since we were felt to be inseparable, I was neither experienced as a ‘real person’, separate from herself, nor did I exist outside the sensations that I inspired, produced or provoked for her. My voice was also equated with Karen’s hand and, as she had managed to find an exact duplicate for my blanket and sleuthed out and found the perfume I usually wore, she was also able to reproduce the comforting visual, tactile, and olfactory sensations that she experienced while she was in my physical presence, no matter the place or time of day. Additionally, Karen’s thumb – sucked much Downloaded by [New York University] at 03:54 14 August 2016 of the time during the analytic hours and (when no one was watching) between the hours – was not a transitional object that functioned to bridge a gap between us during times of felt separation. Instead, the sessions, my voice, and the blanket held in her hand against her face functioned to ‘re-charge her thumb’, so that its utility – as concrete proof of our indivisibility – could retain the power to smooth out the sensations of the jagged and potentially terrifying agony of the separateness and the equally unbearable ecstasy of our reunions. Eventually, Karen began to notice that her clever maneuvers had a ‘short half- life’. They clearly failed to sustain her throughout prolonged holiday breaks, when we would be ‘out of touch’ for two or three weeks at a stretch, and with 184 Judith L. Mitrani

time, these tactics barely sufficed over longer than usual three-day weekends. As we came to appreciate the function of these manipulations and their limited effec- tiveness, Karen had an important epiphany. ‘I made you up in my brain!’ She said. ‘You weren’t real. But now I realize that, if you aren’t real and I lose you, I have no hope of ever finding you again, of remembering you. And if I’m lost and you’re inanimate, not real, you won’t be able to find me.’ It was becoming clear to us that Karen felt the small bits of understanding she was receiving from me as a sign that there was both an inside and an outside, a Dr M. and a Karen, sometimes linked together by tolerable emotional encounters and a growing experience of an ‘other’ who might be willing and able to tolerate and to adapt to her needs, while still remaining a separate individual. These events only became relevant as Karen could begin to bear the awareness that we were two very real people, that we were not ‘one pretend figment of her brain’, but two people who could touch and affect one another on a heartfelt if sometimes disturbing level.

A question of motivation I’d like to clarify that quite often, although it appears that patients like Karen destructively defy the therapeutic boundaries, it is important to consider that their motives may include, at least in some small part, an attempt to survive. Tustin referred to these wayward9 patients as suffering from a miscarriage of motivation. Rather than 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 sensation-objects and sensation-shapes that ensure survival on the most elemental level. Tustin would ask patients to abstain from their autosensual activities, while at the same time interpreting their intended function alongside the deleterious side effects of these behaviors as they emerge in the material. Certainly, when patients turn the analytic framework upside-down, permanent damage can be avoided if we are able to maintain a mindful attitude while being overthrown. For example, especially in this era of electronic communications (i.e. voicemail, texting, tweeting, and email), patients seek and often do manage to provoke contact with us outside agreed-upon hours. In doing so, they challenge the analytic boundaries, perhaps because they have no flexible boundaries of their Downloaded by [New York University] at 03:54 14 August 2016 own. These patients often fall outside the realm of the known and we may need to be willing and able to fall with them for a time, while maintaining our capacity to right ourselves and them through hard-won and thoughtful interpretative understanding. Throughout the process of developing a narrative of shared meaning, enactments of all kinds can be put to good use. Perhaps the experience we gain through free- falling with our patients may stimulate us to stretch our imaginations to the fullest. Learning from experience may help us bear to ‘know’ what we do not know that we know, to access our faith (Bion 1970) in the analytic process, in the unconscious, and in human relationships. Perhaps having such experiences, rather than trying to Technical extensions for analysis of autistic states in adults 185

avoid them at all costs, may enable us to reach, to catch, to bear, to better apprehend, and to make known our understanding through our interpretative contributions. Regarding the treatment of the autistic child, Dick, Melanie Klein wrote:

In general I do not interpret the material until it has found expression in various representations … however where a capacity to represent … is almost entirely lacking, I have been obliged to make … interpretations on the basis of general knowledge. (1930: 246)

It is this author’s belief that our ‘general knowledge’ must include not just our theories, but a first-hand and hands-on experience of what it feels like to be physically helpless, dependent and as-yet-unintegrated, stemming from our own experiences in the transference as analysands and from our familiarity, as analysts, with this dimension of the countertransference (Mitrani, 1992, 1993, 1998, 1999, 2001, 2007a, 2007b). Perhaps one of the most challenging happenings for the analyst in this sphere is related to a specific feature of autistic states which warrants explication.

The object in the periphery Tustin (1986a) linked a particular class of auto-generated sensation-shapes to the well-known observation that autistic children frequently do not look directly into the eyes of others, instead taking in a great deal by peripheral vision. On this topic, she wrote:

This over-developed fringe awareness means that fringe-shapes are formed which can never be clearly focused and which constantly elude the children. Autistic children show that they are constantly tantalized by such elusive, self-generated shapes … In the end, such shapes are not tranquilizing but tantalizing [and] also impede 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 became frightened of her Downloaded by [New York University] at 03:54 14 August 2016 eyes. This separateness had been forced upon their attention before they were ready for it. In Winnicott’s terms it ‘impinged’; they did not find it out 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, attending instead to the fringe shapes they could make by looking out of the corners of their eyes. This brought some sort of order into their bewildering world, but like will-o’-the-wisps, these side-long shapes eventually isolated them in immo- bilizing bogs, cut off from contact with other human beings. (p. 154) 186 Judith L. Mitrani

This variety of soft, blurry, indistinct autistic shape (Tustin 1984b) initially creates a sensation of at-one-ment with the primary environment. I believe it may be useful to notice that there exists an analogous phenomenon, commonly encountered in our work with adult patients in analysis. For example, many analysts have the experience of speaking to a patient who responds as if the analyst has said nothing. That is, the patient goes right on without reference to the analyst’s verbal communication. The sense one gets is that the patient has rolled over, run through, or maneuvered around what the analyst has said. Although kept in the periphery of the patient’s attention, at times the analyst can detect some faint refraction of her communications, embedded in seemingly unrelated stories that the patient tells about himself in relation to others. Alternatively, the analyst might detect a slight rephrasing of what she has said, presented as though it is the product of the patient’s own insight. This situation is quite common and may be the result of a displacement subsequent to some resistance in patients who are neurotically organized and for whom separateness is a narcissistic issue. In the classical Kleinian model, this situation is often taken up as an expression of envy and a sign that the patient is usurping the function of the analytic breast, so to speak. However, the analyst may wish to entertain an additional dimension of significance with regard to this phenomenon: that her intervention has inadvertently forced an awareness of separateness upon the patient’s attention before he is able to contend with it. As such, the interpretation may constitute an impingement that is painful beyond all bearing. In reaction to this impingement, the patient may swerve away from the pain and from the mother-analyst who is felt to be the source of a reality that he cannot face head on. In the countertransference, the analyst can detect this state as it will often engender in her the feeling that she does not exist. It is as if she were invisible or unheard, except for the faint echo of her words in her own solitary mind. At other times, the patient’s response may resemble the echolalia of the autistic child. When encountering this phenomenon, the question of motivation is essential for the analyst to consider. In extreme cases, wherein the awareness of separateness is an existential issue, the patient may at first seem relaxed, unperturbed by what the analyst has said, and may simply go on as if untouched. Sometimes there can be varying degrees of weepiness or other bodily signs (e.g. coughing, flatulence, fidgeting) indicating Downloaded by [New York University] at 03:54 14 August 2016 that the analyst has punctured the protective capsule and signaling that a process of dissolution (which I will elaborate upon further below) has begun. However, powerful efforts to staunch the flow from the wound of two-ness work rapidly to seal up the protection once again, and such embryonic signs of having been being touched may lead to a ‘dead end’ that is frequently marked by the patient’s complaint, registered either directly or obliquely, that he does not feel the analyst to be alive or present. Ideally, the analyst may be able to convey, both gently and firmly, her sense of the patient’s experience. Her understanding needs to address three distinct areas. The first area has to do with acknowledging the pain and dread of Technical extensions for analysis of autistic states in adults 187

separateness ‘beyond all bearing,’ provoked by the analyst’s intervention. The second concerns the ways in which the patient deadens the insufferable pain and attenuates this nameless dread. Finally, the third area must recognize the ways in which these self-protective maneuvers culminate in the feeling of ‘being neither here nor there’ with an analyst who is either a ‘nobody’ or a tantalizing somebody, out of touch and just out of reach in the periphery of the patient’s existence (i.e. the side effect of this protective maneuver). In time and with patience, a process of working-through may lead to an increasing capacity to tolerate separateness and, in place of the dead end of therapeutic impasse, the analytic couple may be able to move forward on the road toward emotional and mental development.

The dread of dissolution In some individuals, autosensual protections against the awareness of unbearable separateness or the turbulence of real emotional closeness are like the thorny vines surrounding the castle where the Princess Aurora lay protected from the prick of death, or the wall of fire that encircled Brunhilde in Wagner’s ‘Ring’. The analyst needs to be courageous, as well as ‘charming’ and imaginative, in order to engage these ‘sleeping beauties’ when faced with the poisonous pricks and the fiery flames of intense emotion. As Tustin once said:

These patients will break your heart, just as they had once been heartbroken. The therapist can provide an object lesson in bravery and resilience, while suffering life’s heart breaks with the aid of human relationship. (Personal communication, 1989)

Perhaps personal analysis, supervision, and peer consultation could be helpful for managing the heartbreak as well as the primitive dreads that must first be borne by the analyst before the patient can be expected to bear them on his own. Among these dreads, the ‘dread of dissolution’ is predominant. The term dissolution (Tustin 1986a) describes the awesome danger associated with the awareness of otherness in earliest infancy, with the events of psychic and physical changes, and with the emotional havoc engendered by such changes. Downloaded by [New York University] at 03:54 14 August 2016 Changes are often felt, on a primordial level, as a transformation from a solid existence to a liquid state. The terrors of spilling out of control into a bottomless abyss, and even evaporating into nothingness (Mitrani 1993), threaten to prevail when left uncontained. When the analyst dares to infiltrate the blockade imposed by autosensual protections, she also becomes exposed to these same dangers, especially while ‘taking the transference’ (Mitrani 2001). This most difficult aspect of our work is an unconscious act governed by unconscious factors in response to emotional happenings actually experienced and suffered by the analyst to some significant degree. This is essential to what Bion called the maternal function of ‘reverie’: 188 Judith L. Mitrani

the attentive, actively receptive, introjective, and experiencing aspect of the containing object. Perhaps our capacity to take the transference is never so important as it is with these individuals who have spent much of their lives ‘wrapped tight’, as one patient explained with deep regret. The patient’s history (most convincingly as it unfolds in the transference- countertransference continuum, where we have the chance to learn from experience) approximates the basic constellation underlying pathological autosensuality. It is common for Mother’s emotional accessibility to be impaired, especially while in a narcissistically vulnerable state such as is often the case during the pre- and post-partum period. The mothers of autistic patients have often been insufficiently supported and are frequently disheartened, depressed, or preoccupied by nature or by circumstance around the time of giving birth (Tustin 1981). Consequently they temporarily withdraw, recoil, reject, or turn away from their babies on an emotional level, especially when the baby is felt to be a source of potential narcissistic injury.10 In cases where a baby is exceptionally sensitive and expressive, its cries may reinforce the mother’s sense of being a failure as a mother. If such avoidant behavior on the part of the mother extends beyond the baby’s own limited innate capacity to sustain itself, normal projective identification (Bion 1965) – at first aimed at communicating unbearable states of excitement, pain or terror in search of reception and transformation – will grow to hyperbolic proportions. Eventually the result is a sealing-off of vital aspects of the infant’s nascent self, along with its capacity to perceive emotional happenings. Bion’s (1974) description of the sequence that follows a failure in maternal containment may depict a common precursor to autistic encapsulation.

The infant takes back into itself the sense of impending disaster, which has grown more terrifying through the rejection of the mother and through its own rejection of the feeling of dread. This baby will not feel that it gets back something good, but the evacuation with its badness worse than before. It may continue to cry and to rouse powerful anxiety in the mother. In this way a vicious cycle is created in which matters get worse and worse until the infant cannot stand its own screams any longer. In fact, left to deal with them by itself, it becomes silent and closes within itself a frightening and bad thing, something which it fears may burst out Downloaded by [New York University] at 03:54 14 August 2016 again. In the meantime, it becomes a ‘good baby’, a ‘good child’. (Bion 1974: 84)

When we begin to reach some genuine understanding of the specific plight of the infant in the adult patient in analysis, the protective wraps that make up the encapsulation may further loosen their hold and intermittently fall away, gradually allowing ordinary human experience to penetrate (Mitrani 2006). It is, however, important to keep in mind that the terrors of slipping away into nothingness or bursting open with excitement – provoked especially by absences and reunions – do re-emerge with regularity, followed by the redeployment of the old, Technical extensions for analysis of autistic states in adults 189

faithful, and familiar protections. This inevitable cycle renders the process of ‘working through’ (Freud 1914a) both painstaking and protracted. One patient, Julia, was able to help me to get a sense of the seamless quality of the protective fabric within which her infant-self was swaddled. She was put in mind of the filmAlien and described how the creature – a monstrous infant – came to the surface, breaking out of the belly of its host, destroying him and threatening those who tried to help. She likened this scene to my efforts to be in touch with what she called her ‘original self’. She was convinced that we would both be destroyed in the process. Indeed, Tustin (personal communication 1988) said of the autistic barrier, ‘When this brittle self-sufficiency can no longer be maintained, the situation is devastating for [the patient] because the basic sense of going-on-being is felt to be dependent upon maintaining such a barrier.’ I believe that an in-built assumption of the analyst’s vulnerability, for which patients frequently find evidence, may be linked with this problematic (Mitrani 2007b). Such evidence sometimes leads to an exaggerated fear of the analyst coming in contact with the infant-self that has been experienced as an alien, ‘frightening and bad thing’, which must be kept silent and closed-off in order to prevent the mother-analyst from becoming overwhelmed. One example of this kind of situation comes to mind from the analysis of a man with whom I was working at the time of the big earthquake in Los Angeles in 1994.

Leonard Leonard, a man in his forties whose mother had suffered a psychotic breakdown subsequent to his birth, had been in analysis with me five days per week for several years. Over time, he had built up, from experience, a firm conviction regarding my reliable resiliency, which had allowed him to relinquish many of his autosensual protections. Leonard both lived and worked more than an hour’s drive from my office. With regularity he traveled over one of the main east–west arteries through the city to attend his analysis at the end of each day. The earthquake, the most destructive in many years, had caused the collapse of this highway and there had been an announcement of a curfew to be imposed after dark for the entire Los Angeles area. Around noontime, eight hours after the Downloaded by [New York University] at 03:54 14 August 2016 earthquake struck, Leonard rang me up to ask if I would be in my office. He wondered if he could safely come ahead to his hour, and expressed concern that he would not get through or, at the very least, that he might be delayed. Ordinarily, I might have confirmed that I would be there for his hour whenever he arrived and would have taken up his doubts during the hour. Instead I said, ‘Perhaps with the collapse of the road and the security precautions, it may be inadvisable to come ahead.’ Noticeably taken aback, Leonard replied that he would let me know what he decided later in the day. Indeed he left me a message, just prior to the time he would be leaving work to come to see me, stating that it sounded like it would be best for him to return home and try again tomorrow. 190 Judith L. Mitrani

The next day Leonard began the hour saying that, with the collapse of the highway all the streets were packed and there was no way to come through. He wondered how we could continue until this was repaired. ‘Maybe it will never be the same, and how can you trust them to rebuild it so it doesn’t happen again. I could have fallen off and been killed. I guess the stress and the weight of everything was too much.’ Leonard then became very withdrawn, sleeping through much of the hour. I thought it likely that he had taken what I said on the telephone the previous day to be a sign that, like the highway that connected us, I too had ‘collapsed’ in the quake under too much strain. Perhaps while feeling that I was protecting myself from his substantial concerns at a time when my own were just too much to bear, he had withdrawn from contact and had given up his approach to me. In the ensuing hours, we were able to adequately address this expression of mine and his interpretation of it in earnest, taking up his initial call as an attempt at reality testing and an expression of his need for reassurance. Gradually we repaired the emotional earthquake that my ‘collapse’ had created for Leonard, first in the transference and later in the context of his initial experience of Mother, which had led to the protective encapsulation and arrest of his original spirit and had obstructed the path of his mental development.

Resistance and collusion: a coincidence of vulnerability in analyst and analysand In concluding, I will put forward one last consideration specifically regarding the countertransference. Since the patients I am referring to, perhaps more so than others, resist interpretations that directly address the infantile transference, they also stimulate the analyst’s own resistance to being in contact with states of maxi- mal dependence and vulnerability through this very rejection. At times, this stimulant can be so potent that the analyst may unwittingly collude with the patient by hardening herself, creating her own barriers to emotionality. Noticing the crucial juncture when what the infant-in-the-patient communicates resonates too strongly with what the infant-in-the-analyst has endured is key. This resonance may evoke a range of reactions rooted in happenings from the analyst’s own beginnings, further complicated by those happenings in the early life of the Downloaded by [New York University] at 03:54 14 August 2016 patient as these are communicated unconsciously and often non-verbally. For example, a patient’s material may stir up repressed memories of our own physical injuries or disabilities, psychic trauma, and the bodily and mental constraints that we have been subjected to as infants and toddlers. I recall a period with one analysand during which I was faced with a pattern of acting out that required patience for many months. During this period, I was profoundly disturbed by a sense of ‘nowhere to turn’, which was represented in my dreams in such a way that often evoked long-buried memories of having worn leg-braces at nighttime and during naptime to straighten out my feet between the ages of one and three. These braces took the form of Oxford-type shoes, separated by a steel Technical extensions for analysis of autistic states in adults 191

bar that constricted my ability to turn over in my crib. I was convinced that these dreams (and other reactions and associations of mine that were consonant with the dreams) somehow held the key to the meaning and significance of my analysand’s dilemma and that they constituted the essential material from which I might derive an interpretative intervention that could move us forward on the analytic path. The struggle to tolerate feelings of constriction, defect, despair, and helplessness was worthwhile, as it eventually led to the uncovering of (as well as the ways and means of teasing out) the transgenerational roots of one of the major dynamics in the patient’s personality structure, which we were gradually able to trace both to the early traumatic beginnings of the patient’s mother and her adaptation to that trauma, as well as certain characteristics of the maternal grandmother. Rather than relying on adult experiences, professional competence, training, and, most especially, theories to circumvent this kind of awkward happening in the countertransference, with determination and faith in the process the analyst may find the mettle with which she might forge those unbidden emotional reactions and physical sensations into useful tools for understanding. Finally, although some patients may nudge us to attend only to what is occurring outside the room, and frequently try to put us off the trail (e.g. when they tell us, ‘This is not about you!’), the analyst needs to find a way to remain alive and attentive to the infantile transference and her role in it. To be carried off by current external events or diverted toward a historical past that is already well- traversed by both members of the analytic couple may lead to a fortification rather than a relaxation of the patient’s autistic barriers. The analyst’s open- mindedness to communications from within ‘the dark acorn of the heart’, when these momentarily surface, may contribute toward facilitating a wholesome emergence of self.

Notes 1. Originally published in (2011), The International Journal of Psychoanalysis, 92: 21–42. 2. When the object is unable or unwilling to receive, to make sense of, and to reflect the baby’s own internal state, or when the object projects her own internal state onto the infant, intentional states will not be symbolically bound and the developmental basis of Downloaded by [New York University] at 03:54 14 August 2016 the self-structure will be absent (Fonagy and Target 1996). The weakness of such a self-image leaves the child with affective and perceptual happenings that remain nameless, confusing, and frightening, what Bion considered to be unmetabolized or uncontained (Bion 1962a) and what this author has termed ‘unmentalized’ (Mitrani 1994). 3. Sidney Klein (1980) first described patients who, despite the appearance of progress in the analysis, remain untouched in some essential way due to encapsulating forces that cut them off from the analyst as well as from the rest of the personality. Klein posited that walled off in these cystic areas are intense and unbearable fears of ‘pain, and of death, disintegration or breakdown’ (p. 400) related to unmentalized experiences of separateness of early infancy. He suggested that such phenomena ‘are strikingly similar to those observed in so-called autistic children’ (p. 400). Compellingly, novelist Patrick Süskind (1986) writes of this encapsulation phenomenon in the extreme. 192 Judith L. Mitrani

He describes his protagonist Grenouille, born of an overly preoccupied, deprived and unsupported mother. His means of survival is compared to that of a tick:

For which life has nothing better to offer than perpetual hibernation … which by rolling its blue-grey body up into a ball offers the least possible surface to the world; which by making its skin smooth [and] dense, emits nothing … makes itself extra small and inconspicuous [so] that no one will see it and step on it. The lonely tick, which, wrapped up in itself, huddles in its tree, blind deaf and dumb and simply sniffs … for the blood of some passing animal that it could never reach on its own power … the tick, stubborn, sullen and loathsome, huddles there and lives and waits … for that most improbable of chances … and only then does it abandon caution and drop and scratch and bore and bite into that alien flesh … The young Grenouille was such a tick … encapsulated in himself [he] waited for better times. (p. 25)

4. All clinical material concerns patients who, after the initial evaluation sitting up in a chair, were engaged in analysis reclining on a couch utilized for that purpose only four or five times per week. 5. Tustin distinguishes autistic objects from ordinary objects (inanimate or animate) in that the former are not related to as objects, but rather used for the tactile sensations which they engender upon the surface of the skin of the subject. Autistic objects differ from ‘transitional objects’ (Winnicott 1958c), which are a combination of ‘me’ and ‘not me’ that constitute a bridge that links the two together during physical absence, while autistic objects are barriers to the awareness of ‘not me’ and as such are an impediment to growth and development. Autistic shapes are differentiated from objective shapes (such as a square or a circle), in that they are idiosyncratic, endogenous swirls of sensation produced upon the surface of the skin or internally with the aid of bodily substances or objects. These distinctions, first based upon observations with autistic children, are now widely extended to include numerous other behaviors observable in adults and children with an enclave of autism, which may be conceived of as sensation-dominated delusions. The key word here is ‘sensation’. Such sensations either serve to distract one’s attention away from insufferable happenings, providing an illusion of safety, strength, and impermeability, or they may have a numbing or tranquilizing effect upon the individual, which blocks out some terrifying awareness. 6. Tustin (1986a) defines these as ‘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’ (p. 85). 7. Due to the limitations of the scope of this chapter, I have not addressed in depth the differential diagnosis between dissociative and autistic states, a topic that deserves a Downloaded by [New York University] at 03:54 14 August 2016 paper of its own. Suffice to say that, although both states are related to trauma,the dissociative state can be included in the object-related category. It may be expressed in amnesia (forgetting) or fugue and dissociative/multiple personality disorders (in which the split off or repressed aspect(s) of self can be given life/expression, at least temporarily). In contrast, the encapsulation common to autistic states constitutes a virtual isolation chamber in which the unmentalized traumatic perception (as well as what Meltzer and Bion described as the associated aspect of the dismantled perceptual apparatus) is hermetically sealed off from future development, expression, or memory. Such relatively advanced defenses as splitting and projection, repression, denial, and displacement are not relevant in the autistic state. As such, traumatic events can neither be remembered nor forgotten. Additionally, the traumatized aspect of the personality cannot be lived (in the ordinary sense of the word) either tentatively/alternatively. Technical extensions for analysis of autistic states in adults 193

8. Dr Theodore Mitrani pointed out that the word ‘ecstasy’ comes from the Greek term ex stasis. So it appears that, in ancient times, the Greeks knew something about the desta- bilizing effect of experiences of joy, beauty, and love, which may become overwhelming to the baby when left unmet and uncontained by the mother (J. Mitrani 1998). 9. In a scholarly paper drawing together the work of clinicians from several orientations, American analyst Ruth Stein (2005) discussed patients who were seen as engaged in non-sexual perverse relationships with their analysts whom they approach as inanimate things, manipulated in the service of creating physical sensations that camouflage hatred and paranoia. She coins the term ‘false love’ to characterize the nature of relatedness that may appear affectionate, but which circumvents affect. 10. In the interest of clarification, although Tustin often stated that Bettleheim’s (1967) notion of ‘the empty fortress’ was an apt way of describing the autistic protection, she explicitly disagreed with his characterization of the mothers of autistic children when she wrote, ‘I have a great deal of sympathy for these mothers. In 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’ (1986a: 61). Consistent with Tustin’s attitude, perhaps it is essential to take into consideration the possibility of either a failure in the environment, a failure of constitution, and/or a combination of both: what I have referred to as a ‘coincidence of vulnerability’ in the infant-mother couple (Mitrani 2003). Downloaded by [New York University] at 03:54 14 August 2016 Chapter 13 Ghosts in the swamp Some aspects of splitting and their relationship to parental losses1

Kate Barrows

In this chapter, I describe a patient whose extreme withdrawal seems in part to have taken place in response to inadequately mourned losses in her parents’ lives. I address some central aspects of the first three years of her analysis. The patient shows in particular three types of relationship to her objects. The first is a state of idealised retreat in which she starves herself of food and contact with life and fills herself up with books and television. She is in charge of her own supplies. The second, which becomes manifest when she is beginning to emerge from her retreat, consists in desperately clinging to an idealised object whose loss would leave her utterly bereft. This protects her from the third kind of relationship, which is one of persecution, where a damaged object full of ghosts is felt to be preventing her from having a life. The ghosts represent her parents’ internal objects as well as her own projected feelings. As well as the split between idealised and persecutory objects, a split between sensory and psychic functioning is also employed in her attempts to keep the ghosts at bay. This is reproduced in the analytic relationship, where the patient clings to an adhesive relationship to the analyst as a helpful figure in order to avoid the persecutory elements associated with thoughts and emotions. Fraiberg et al. (1975) described as ‘ghosts in the nursery’ the frightening figures – remembered or unremembered – from the parents’ childhoods who take up residence in the nursery of their own children and dominate their current relationships. The influence of the ghosts is determined by the extent to which the affects associated with difficult experiences have been repressed and the Downloaded by [New York University] at 03:54 14 August 2016 children – now parents – have dealt with their pain by unconsciously passing on the suffering to the new generation. Fonagy et al. demonstrate that where the caregiver’s own damaging experiences intrude, ‘the fear of the mind of another can have devastating consequences on the emergence of social understanding’ (1995: 258). They argue that the child’s capacity to develop a model of the mind that can contain and make sense of their own experience entails feeling that it is safe to know the mind of another. ‘The child gets to know the caregiver’s mind as the caregiver endeavours to understand and contain the mental state of the child.’ My patient told me in an early session that she was always afraid and this fear drastically coloured her Aspects of splitting and their relationship to parental losses 195

relationships to those around her as well as limiting her capacity to make sense of her own experience. I have found it useful to bring together these ideas with Bion’s concept of a split between the psychic and the material. Bion describes a type of patient who cannot learn from experience:

The infant receives milk and other creature comforts from the breast; also love, understanding, solace. Suppose his initiative is obstructed through fear of aggression, his own or another’s. If the emotion is strong enough it inhibits the infant’s impulse to obtain sustenance … Fear of death through starvation of essentials compels resumption of sucking. A split between material and psychical satisfaction develops. (1962a: 10)

In the patient whom I shall describe, this split seems in part to have developed to protect her from the ghosts inside her parents. I suggest that it is not only ‘another’s’ aggression that is feared, but also the other’s aggressive internal objects.

The analysis Miss Y. was referred for psychoanalysis in her late twenties by a National Health Service psychiatrist in South Wales. She had already been in therapeutic groups and had had once-weekly conselling with a psychologist for a year but these forms of treatment had not managed to shift her presenting symptoms of bulimia, chronic withdrawal from life and escalating suicidal thoughts. I was asked if I would consider seeing her as an alternative to much more costly long-term hospital in-patient treatment and the NHS agreed to fund five-times-a-week psychoanalysis. She had to travel over an hour on trains and buses to get to her sessions and attended very regularly. She felt that her analysis was her last chance. Miss Y. was the second of several children born in quick succession. She seemed to have turned to her somewhat idealised father to avoid a difficult relationship with her mother. She saw her mother as intrusive and lacking in boundaries though she also described her as being kind and worried about Miss Y. Her father died suddenly in her adolescence at a time, she said, when she was arguing Downloaded by [New York University] at 03:54 14 August 2016 with him for the first time in her life. She then felt that she had to try to keep her mother out although she in fact remained very tied to her and was unable to form other relationships. She lived around the corner from her mother and never saw anyone else, refusing to acknowledge her mother’s or her siblings’ partners. She said that all she ever did was go to the library or stay in her room reading and watching television. Her periods stopped when she was 21. She much later connected this to her weight loss. She had been overweight at university. She dropped out of college and developed anorexia and then bulimia, which she had had for several years at the time of the referral. Her teeth had been damaged and she was having hormone 196 Kate Barrows

treatment to prevent bone damage. She was told that so many years of eating disorders and of hormone treatment might have affected the possibility of restart- ing her periods and of conceiving children. When I first met Miss Y. I was struck by how pale she was, almost ghostly. She was later to describe herself as a ‘shadow person’. She was pretty with a lot of long auburn hair and large blue eyes. She was very thin and moved in a stylised way like a mannequin, with exaggerated hip movements and pelvis thrust forward. Her eyes moved constantly, sliding over the furniture and myself and only meeting mine very occasionally and fleetingly when something I said touched her feelings. Her neck also moved from side to side, giving an impression of avoidance and inability to settle. Her clothes were like a conglomeration of opposites: pretty, white feminine blouse and big dirty men’s shoes, carefully matched colours and neglected, badly chewed cardigan cuffs. A feature that puzzled me from the start as well as giving me grounds for hope was Miss Y.’s voice. There was a striking contrast between her withdrawn way of life and the expressiveness of her speech. While at times she could sound somewhat unreal, as though she was telling a story, on the whole her voice seemed direct, alive and musical, conveying quite a range of emotions. I have wondered whether in some way her voice itself served as a container for the feelings that could not be employed in relation to other people, like the musicality of an autistic child. Likewise, the images that she came up with to express her feelings were often evocative and had a directness and vividness that were in contrast to her withdrawal from human contact. She did make direct contact with me, but the communication would often get lost or spoilt. Although Miss Y. expressed her desperation about herself when she came for her initial consultation, when her analysis started it soon became clear that she was entrenched in a retreat that she was terrified of leaving and that at times she felt to be far superior to other modes of existence. She talked about how bad she felt about having thrown away all her opportunities, particularly in her education and her social relationships, but then went on to describe dieting and filling herself up with books. As she spoke she took on an arrogant tone, saying how she could have such intense experiences with books that she couldn’t see how people bear to live their boring lives, with mortgages, children and jobs, although there must be some ‘compensations’. She had retreated from a painful awareness Downloaded by [New York University] at 03:54 14 August 2016 of what she was missing, and she was showing me what we would have to contend with if she was to be able to make use of the analysis. Her retreat was a place that seemed to her to be superior to the realities of life, which she was looking down on as though she now had no needs of her own and nothing to lose. In contrast to many patients whose insight is able to develop during a session, partly through analysis of the conflicts aroused by gaining insight, Miss Y. would beat an unstoppable retreat from understanding, seeming to flee in panic from the possibility of sustaining it. She would then talk of how important she felt it was for things to be ‘pleasant’, ‘comfortable’ and ‘peaceful.’ This had a deathly quality. (Her ‘pleasure principle’ was laden with qualities of the ‘death instinct’ (Freud 1920).) Aspects of splitting and their relationship to parental losses 197

Early on in the analysis this state of mind seemed split off from her occasional capacity to be aware of what she was missing, and she would shift quickly from one to the other with no apparent awareness of the contradiction or the connection. She seemed to be protecting herself from acute envy of other people’s lives, including her analyst’s, and from her enormous sense of despair and of loss. Steiner (1993) has pointed out that a psychic retreat can be a retreat from persecutory or depressive anxieties or from fears of loss and in my patient the three often seemed closely linked. I also wondered whether she was afraid of having anything for herself, especially a capacity for insight. Her feelings of exclusion were often avoided by extreme misanthropy. She hated people in general, in the street, on the bus travelling to and from her sessions, and she professed utter callousness towards anyone with needs. Children, old people, victims of violence were all subject to cold and sadistic scorn. This seemed related to her feelings of jealousy, envy and possessiveness and to be intensified by the fact that she deprived herself and her needy aspects of the possibility of receiving concern and support. She was chillingly aware of her destructiveness. She also saw herself as ‘a bad lot’ for being so full of hatred and she felt that she did not deserve to be helped. She felt that her negative feelings made her completely unacceptable, a social and psychological outcast. In the first year of her analysis, in particular, the retreat that Miss Y. was so attached to had a very autistic quality to it. There were numerous images familiar from work with autistic children: an image of spinning round and round in a dark blue sky with twinkling stars far away, an image of her whole self bleeding out, of having a vital bit missing, a feeling of being like a tortoise without its shell, or of living at the bottom of a dark well and only occasionally daring to come out. Tustin (1981) brought into focus the contrast between a hard, protective shell and a hypersensitive, vulnerable part of the personality in autistic children. She understood autistic children to be protecting themselves from feelings of loss, the loss of an object that is experienced at a part-object level as a part of themselves. They hide behind their shell or cling to an object or to their bodily sensations in order to prevent or to shut out unbearable feelings: their split between physical sensations and psychic experience is massive. Adults with marked autistic features effect a similar split, but in more subtle or hidden ways. S. Klein has Downloaded by [New York University] at 03:54 14 August 2016 described how some of these patients have ‘an almost impenetrable cystic encapsulation of part of the self which cuts the patient off both from the rest of his personality and the analyst’ (1980: 395). These patients are prone to think concretely, and despite being highly articulate may use speech ‘to maintain a link with the analyst or to avoid the link, rather than as means of communication’ (1980: 400). The split in Miss Y. between a material use of language and the feelings that she thus avoided became evident in relation to her difficulties in learning. She was thought to be less intelligent than her siblings and felt very aware that her younger siblings could read and write before she could. ‘What were you 198 Kate Barrows

doing while they were learning?’ I asked. ‘Looking on,’ she replied. She described much of her childhood as having been spent listening or looking on rather than joining in with others or getting on with things independently. She formed very few friendships and from early on felt that her siblings had the friends, the capacities and the life that she lacked. It seemed that from early on she may have projected her capacities (which she described as the bit of vital equipment without which she could never function like other people) into the nipple and breast and then into her mother, father and siblings. In the same way, she projected into me the capacity to make links and waited for me to do it for her. She also felt certain that my other patients were much better at having analysis, that they learned more and changed more quickly or successfully. She also felt intensely jealous and envious and it seemed that her fear that these feelings could not be contained contributed to her difficulty in reclaiming her own capacities. There were many illustrations of Miss Y. ‘looking on’ and listening but unable to develop. She had memories of endlessly looking on as a child, often with no wish to participate in life. There was a dream of a fish with huge eyes, in a tank too small for it and unable to grow and a dream that she was looking after a little silver-grey rabbit with large ears and neglecting it. She put it in a brown paper bag in a drawer and asked someone how to look after it. They told her that she was starving it and that it needed to be taken out and fed properly and allowed to run around. She said that this dream was like others that she used to have as a child, except this time she was asking someone to help her to understand so that she could know what to do. The rabbit was like the rabbits that she had had as a child, and she felt guilty because although she remembered being upset about their dying she couldn’t remember why they had died and she suspected that she had actually let them starve. This material illustrates the split that she effected between the sensory and the psychic, in that her ears or eyes could be used or even overused but she could not link what she saw and heard to her feelings or her experience. The part played by her perceptions had become enlarged, as represented by the large ears of the rabbit or the huge eyes of the fish. However, in the dream about the rabbit, she recognised that she needed understanding to free herself from this state of passive perception so that she could be ‘fed properly and run around’, which implied Downloaded by [New York University] at 03:54 14 August 2016 awareness of the need to digest her experiences and to feel free to move and to engage with life. She felt responsible for the neglect of her needy aspects. The paper bag and the small tank also suggested an internal container that constricted her emotional growth. These dreams can also be seen to be connected with her eating difficulties. When she was anorexic she did starve herself, like the rabbit. The overuse of her perceptual apparatus in both dreams is in some ways similar to the overeating in her bulimia, where she took in too much but could not allow herself to digest it. Williams reflects on the use of a ‘no-entry system of defences’ (1997: 115) by some individuals with eating disorders. She describes a reversal Aspects of splitting and their relationship to parental losses 199

of the container/contained relationship in which the child has been used by the parent to contain their projections. The child becomes a receptacle for the parents’ internal objects and anxieties which are experienced as ‘foreign bodies’; he develops strategies to keep these out or to get rid of them. Miss Y.’s split between sensory perceptions on the one hand and thoughts and feelings on the other can be seen as part of her ‘no-entry system’. She responded with relief to the containment provided by the analysis, in that her symptom of bulimia disappeared within a few weeks of her starting her sessions, though there were, as far as I know, two occasions prior to holidays when she made herself vomit. However, it seemed to me that the bulimia was enacted in the analysis and was expressed in the way in which she responded to my words. She would seem to be hungry for understanding and would avidly take in what I said, in an intellectual kind of way, sometimes giving me quite an accurate summary. But often the understanding did not seem to get metabolised and I came to see that she was regurgitating versions of interpretations that I had made without having allowed the content to affect her at a deeper level. She seemed to be using her mind in the same way as her ears and eyes, as a passive receptor, but then getting rid of what she had swallowed before she could digest it. For my part, I sometimes felt under pressure to say too much or to try to get her to take things in too quickly. She was very thin and seemed initially resigned to, or even relieved by, her probable infertility. However, she gradually became terrified of the damage she might have done herself and her chances of child-bearing. She managed to put on some weight and after a year of psychoanalysis had her first period for ten years. The split between sensory and psychic modes of functioning described above was not immediately apparent, as Miss Y. ostensibly had all the asceticism that is more typical of the anorexic than the bulimic patient. Her asceticism was expressed though repudiation of instinctual life and of obvious forms of materialism (see Kestemberg et al. 1972, as well as Anna Freud’s 1966 discussion of asceticism as a repudiation of instinct). Yet, paradoxically, her intake of intellectual fodder was performed in a materialistic way, to fill herself up but not to change or nourish herself. Her reading or television-watching was an escape into Downloaded by [New York University] at 03:54 14 August 2016 a vicarious world that left her completely unaltered. She would say in an offhand way that she did not want to get to know people – she could get to know them by watching the television. She spoke as though getting to know had nothing to do with a relationship, K in Bion’s terms, but was simply an accumulation of material facts, and at times she related to her analysis in the same way. Yet it became clear, for instance, from the dreams described above, that her overuse of her perceptions did not lead to development. She could accumulate sense- impressions but not learn from them. Her kind of materialism might be termed materialism of sense impressions. It served to protect her from frightening objects as well as from her own feelings, which she felt were too dangerous to experience. 200 Kate Barrows

She told me on one occasion that she felt like a child in a Japanese legend who kept reading and reading to keep monsters, terrors and ghosts at bay. As the analysis progressed she gradually became aware of the barrenness of her retreat. After eight months of analysis there was a session in which she talked of not having minded too much seeing her mother and mother’s boyfriend at the weekend. (This was in contrast to her previously having refused any contact with them as a couple.) She seemed sad, however, and she talked of her fear of not being able to remember anything for an exam. She went on to say that she was thinking about being like Robinson Crusoe on his island, surrounded by books and all that he needs. This seemed at first a calming thought, but then she thought how arid this actually felt, it was more like being Napoleon, imprisoned on St Helena – or was it Elba? Where once there used to be green and fertile vege- tation and goats, now the island seemed a barren place. She imagined being confined to the grounds of the house where he was imprisoned, riven with the wish to get away. I understood this material in terms of a response to her new-found capacity to bear seeing her mother, or her analyst, as part of a couple. She seemed to be retreating to an identification with her father, who did indeed spend much of his time in his study. I said that she wanted to be like Robinson Crusoe, to make herself an island and to feel that books were all she needed. But then she felt barren and bleak, trapped like Napoleon, shut away from life. She agreed, crying, and said that it didn’t work. In reflecting on this material it occurred to me that the question, ‘St Helena – or was it Elba?’ was about whether she was going to be able to escape from her island or be imprisoned there until her death. In contrast to Miss Y.’s attempts to withdraw to an island where she would be unaware of her need for human relationships, fears of loss and rejection often came up before my holiday breaks. When I first met Miss Y. she told me that she had never had a boyfriend. Shortly before the first summer holiday she told me that she had in fact had one brief sexual relationship. She had always felt that she was destined not to have a sexual relationship or to marry. But her curiosity got the better of her and she had a brief relationship with a passing stranger, in order not to get too involved. She was surprised that she felt terribly hurt and upset when he moved on after a few weeks although she had known that he Downloaded by [New York University] at 03:54 14 August 2016 would. It was after this that she became anorexic and amenorrhoeic, determining never to have a sexual relationship again. During the first two years of the analysis, however, she did make considerable progress in her analysis and in terms of external achievements and some social life. She managed to undertake a university course. She gradually developed a friendship with a young man and became sexually involved with him. At first she felt scornful of him for caring for her, but felt that this was a mad response and wanted to understand it. I interpreted this in terms of her scorn of a part of herself that could care for someone or desire them. Then other anxieties came to light: sexual revulsion, fears of engulfment and abandonment, loss of Aspects of splitting and their relationship to parental losses 201

her splendid isolation. But she also felt heartened at this stage, saying that she had never thought that she would feel like being with another person. She was grateful to be wanted sexually and socially and, notwithstanding her many anxieties, began to enjoy her relationships with enormous surprise at beginning to feel so much more alive. She came to her session one day surprised to be feeling grateful towards someone who had woken her up when she had gone to sleep on the bus on the way to her analysis. She felt grateful to me for having helped her so far. These feelings of relief and gratitude contrasted strongly with resentful feelings about being encouraged out of her hiding, and fears about how vulnerable she could become. Her fear of being awakened from her shadow life to a life of intense feelings and sensations only then to lose everything often put me in mind of Oliver Sacks’s 1973 account of the short-lived ‘awakenings’ of patients who had been asleep for twenty years. They experienced a heightened intensity of emotions, sensations and gratitude for being alive, as well as the almost unber- able poignancy that all this would be lost if they were to fall once more into a sleep from which they could never be woken. Miss Y. saw her boyfriend, her work, her analysis as being irreplaceable. If she lost them she would have to go back to her withdrawn state; only now she would no longer be able to tolerate that way of life. She still seemed to feel that she had very little inside her that would help her to sustain loss or change. I felt puzzled as to why her fear of loss was so acute. Miss Y.’s fear that there was no one who could really stand her feelings of ambivalence and loss seemed of central importance in her withdrawal from contact. For instance, there were several sessions that seemed helpful, following which she was able to have a meal and socialise with people, something she had previously been unable to do. She said with evident surprise, ‘Your job must be to find out the good feelings in people as well as the bad ones!’ She seemed heartened but then feelings of exclusion came up and she felt that her positive feelings were getting lost. She told me that she used to love animals as a child and wanted to keep all sorts of pets. Her first pets were goldfish and they developed a fungus; two of them died. She remembered ‘screaming with terror and a sort of frustration’ when she discovered that two of them had fin-rot, and her father said that she shouldn’t keep pets if she was that upset before they even died. In the Downloaded by [New York University] at 03:54 14 August 2016 light of her new-found positive feelings getting lost, I interpreted her fear that I might not stand her feelings about things getting killed off inside her. She then remembered moving house at the age of ten and going back to stay with her best friend. When she came home she missed her friend and was terribly upset, crying a lot. Her father said that she shouldn’t go any more if she was that upset when she came home, so she tried to shut out her feelings and bury herself in books. She did not have any more close friends until after her father died, when she formed an intense friendship with another girl at school. However, she could not stand her friend’s other attachments (even to the friend’s own parents) so she broke off the friendship. 202 Kate Barrows

I commented on her fear that I would not stand her upset feelings about missing me between the sessions, nor her feelings about my other attachments, to my family and other people. She described her father as finding her upset feelings ‘irritating and annoying’, as though he had no place for them. He was a very ‘moral’ person and could not tolerate any jealousy or squabbling; Miss Y. said that it ‘made him go all sad’. She felt inadequate and despairing because she knew that she could not be ‘mature’ enough to please him. This was something that she also feared in relation to me. She initially assumed that my idea of maturity meant not having any jealous, rivalrous or possessive feelings or any feelings of loss. So it was also unsafe to be lively: if she was lively she would also risk coming into contact with the mixed feelings that might meet with rejection. The persistent impression of her father as unable to tolerate feelings, particularly feelings of loss, made sense several months later, in Miss Y.’s third year of analysis. She told me how when her father was eight years old he was looking after his younger sister in the garden and she fell into the pond and was drowned. His sister’s death was never talked about. He felt that his father never forgave him and his mother never recovered. These grandparents seemed to Miss Y. frighteningly stern and disapproving. She used to dread visiting them and felt that she should sit still as though she didn’t exist. A couple of months after she had told me about her father’s sister, she told me that her mother had a younger sister who had a chronic illness throughout her childhood, which was spent in and out of hospital. Her mother referred to her as ‘pathetic’ and she never managed to join in life like other people, remaining a misfit in her adult life. Miss Y. seems to have identified with her parents’ dead or damaged younger siblings. She frequently expressed this in terms of feeling that she was not meant to have a life like other people: on one occasion she thought of hermit crabs who lay their eggs in the sand and when the young hatch out they have to get to the sea. Only one or two survive out of thousands, and she felt that she was one of the ones who were not meant to survive. Thus the factors in her internal environment that militated against the survival of her needy self were her mother’s savage intolerance of vulnerability, seen as ‘pathetic’, and her father’s inability to bear her feelings of loss or to tolerate feelings that might lead to loss or damage. Fonagy et al. (1993) shed further light on Downloaded by [New York University] at 03:54 14 August 2016 the ways in which the ‘ghosts in the nursery’ come to affect the child. Fonagy and his colleagues show how the child’s attachment is less likely to be negatively influenced by their parents’ upset feelings about figures from the past if the parent is able to talk coherently about them and is able to be in touch with the distressing feelings associated with them. It seems reasonable to speculate that the fact that Miss Y.’s grandparents did not talk to her father about his sister’s death seems linked to his fear of negative feelings and feelings of loss. The mother’s scorn of her ill sister suggests that there was insufficient containment for her feelings about the illness and the damage it caused, so that she was unable to feel compassion. The ghosts of Miss Y.’s parents’ dead or damaged siblings Aspects of splitting and their relationship to parental losses 203

and of their own uncontaining parents were present in her analysis, as were their childhood feelings of intolerable grief and guilt. Into these internal figures were also projected her own fear of the range of feelings that might be felt to lead to loss or damage. Miss Y. was very sensitive to my tolerance or intolerance of her feelings, and often seemed to be listening out for signs of experiences inside me that might make it hard for me to deal with her feelings: it was as though she was listening out for my ghosts. The transference was characterised by the combination of an oversensitive child and a potentially uncontaining parent who might harbour dead or damaged objects of their own. Miss Y.’s sensitivity was also extended to my relationship to my ideas. It was a struggle at times to keep my thinking alive and to deal with the feeling of being inhabited by dead ideas or hollow theories. While it was sometimes possible to see that this deadness was related to attacks on my thinking, I also formed the impression that she was afraid that I harboured something frightening. I felt it important to be aware of my ghosts, for instance of archaic internal figures who fear or disapprove of emotions and whom she might experience as making her feel, as her grandparents did, that she shouldn’t exist emotionally. After two and a half years of her analysis her boyfriend went away for a year. This plunged her into a very difficult period as she seemed to have partially lost her old defences without yet having secure enough internal or external objects. The period of ‘awakening’ gave way to a time of great anxiety. She became obsessed with possible losses. A dream from this period in her analysis threw some light on the precariousness of her hold on life and its relationship to parental ghosts. She had agreed to go away to see her boyfriend for a long weekend, which would mean missing a few sessions of her analysis. This was unusual as she attended very regularly. She arrived in a fluster for her session and apologised for being a few minutes late. She talked at first about having been to the doctor’s surgery and having found it hard to leave in case he might think her ungrateful. I linked this to her feelings about missing some sessions and suggested that she was afraid that I might think her ungrateful. She said with relief that she had been feeling really awkward and could hardly bear to talk about it, yet there was such a lot to say. She told me the day of her return. She added that the doctor had been talking with Downloaded by [New York University] at 03:54 14 August 2016 her about the possibility of her having children at some point in the future. She also spoke about her regrets at missing her sessions the following week and explained that she felt that it was no good to be walking around as if her boyfriend were dead and she had been bereaved, rather than being able to think that he had left temporarily and would be back. She seemed apologetic about the need to see him. I interpreted that she seemed to think that I might not realise that she felt that she needed to see her boyfriend and to talk to the doctor about the possibility of having children. I suggested that she was afraid that I would be hurt or angry with her for missing her sessions or even for thinking of having children and for leaving me out. 204 Kate Barrows

She seemed again relieved by this interpretation and went on to tell me a dream that she had had the night before last. She was stuck in a sort of swamp, trying desperately to get out. There were some figures who were like ghosts or corpses, she didn’t know which. They were trying to get her, to kill her. She was absolutely terrified that she would be dragged back and killed. Her sister, Z., was helping her. Z. wasn’t affected and could survive this and help her out of it; her sister was managing to pull her out. Miss Y. was so frightened that when she woke up she had to have the light on all night. It reminded her of the dreams that she used to have about a dead town, but in those dreams she used to be attracted to and interested in the dead places and to like wandering round them, whereas this time she was terrified. I commented on her having left it until today to tell me about the dream and wondered aloud whether perhaps it felt too real. She said that it was terribly frightening; she woke up but felt that it could really be happening. She has always been terrified of ghosts and even recently had to have her light on after her mother told her and her sister about ghosts. I linked this to her fear of me as a mother with ghosts or corpses inside. I reminded her of the fact that she had been telling me earlier in the week about not liking her mother involving Miss Y. in talk about her mother’s old boyfriends and the details of her relationship with her husband and I wondered whether perhaps these seemed like ghosts. She said that she thought they did. In the light of her enormous relief at my earlier interpretations about her fear of my resenting her going away, I also took her dream to be an expression of her fears of the things that I say becoming like ghosts that hold her back; this might be why she had found it hard to tell me about going to see X. She said ‘mm’ thoughtfully when I talked of her difficulty in telling me about visiting X., but then went on to say that she thinks of me as being like Z., helping her out of the swamp: ‘You wouldn’t hold me back.’ I said that although she was aware of thinking of me as helping her like her sister, perhaps she also felt that I had become like a swamp, like a mother with ghosts inside, and then she thought that she would be killed for having a life. She said, ‘Well, why shouldn’t I? I have to have a life. It can’t be helped.’ She then went on to describe, with unusual thoughtfulness, a woman at work who was anxious about her lost bag and a man who had ulcers about his work, saying, ‘They are both so anxious!’ She recollected herself and said that she didn’t know Downloaded by [New York University] at 03:54 14 August 2016 why she was thinking about them. I was struck by the way in which she was describing these people with interest, in their own right, not just as obstacles in her way. I pointed this out, adding that perhaps she wanted to see whether I was like an anxious mother or a preoccupied father. She replied, ‘Well, that is what they were really like.’ As well as this reminding her of her actual parents it was also possible for her to recognise the connection with her thoughts about my being anxious about the missing sessions (bag) or worried (the ulcer) about the future of my work with her. In the above session I did feel that, like her sister, I was gradually pulling her out of the swamp, but I also had an underlying feeling of being like the Aspects of splitting and their relationship to parental losses 205

swamp. The disjuncture in the countertransference seems to stem from the problem that to be experienced as able to help her out of the swamp I also had to be seen as ‘not affected’ by the ghosts, like her sister. Z. was physically pulling her out of the swamp: physical holding on was needed to protect her from the psychic. To be affected, to have feelings, was to be like a mother full of ghosts. There was no middle ground. This made it difficult to talk to the patient using my ideas. One idea that I felt I could not use in this session, for instance, was that she killed me (or her boyfriend) inside her under threat of loss. This had emerged particularly clearly and had been acknowledged after the previous weekend but now the feared contents of her object seemed more immediate than her attacks. I was also aware that her sudden trip to see X. consisted partly in a panicky flight from the feelings that she wanted to leave with me, as well as a wish to sustain her relationship to X. Rather than being in touch with her fears about being left, she became part of the couple who were getting away and I was felt to be left with irreparable internal objects who resented her for going on without me. However, I felt it important to contain this projection of an internal object inhabited by vengeful ghosts; to have returned too quickly to the idea of her need to get rid of her feelings or her aggression might have felt like using the idea in a ghostly, possessive way to swamp her and drag her back. This sort of containment requires a lot of discomfort for the analyst since it can be hard to know whether one is shirking the difficult job of putting something back to the patient or whether one is containing feelings that the patient cannot bear. Perhaps the discomfort is also because of confusion about how much belongs to the patient and how much comes from something that is inside their object and has not been metabolised. I think that recognising this type of countertransference feeling of anxiety about what belongs to whom is intrinsic to analysis of the patient’s problem. The split shown in Miss Y.’s dream between a helper and a frightening object also affected her view of the parental couple who were split along similar lines: father-helper and damaged mother. Material from a session several months later showed this split particularly clearly. In this session the idealisation of the helping object is more pronounced as is the part played by Miss Y.’s resentment of the parental couple. Miss Y. talked of her confusion between Kew Gardens and Downloaded by [New York University] at 03:54 14 August 2016 the burned down Crystal Palace. At Kew she had been taken by her father to see some statues and she particularly liked the griffin because it is made up of different animals, not conceived and born like others. She also remembered her father’s magic stories that she liked to escape into. It seemed that she was turning to a magic father to help her to get away from her burning attacks upon her fragile mother (the Crystal Palace) and on the parental couple who conceive babies in the normal way. She turned instead to a magic, patched-together object to avoid her ambivalence. This threw light upon the fact that when I first met Miss Y. her appearance struck me as somehow patched together, a ‘conglomeration of opposites’. Her objects had not been conceived or put 206 Kate Barrows

together properly so that they could not be assimilated into her personality and her inner life was not free to develop. In the griffin session Miss Y. also became painfully aware of the way in which her resentment of the parental intercourse extended to resentment of my capacity to think fruitfully about her, hence affecting her own thinking capacities. However, her capacity to recognise her own feelings and to think her own thoughts developed considerably after the part played by the parental ghosts had been understood and to some extent worked through in the analysis. She could then begin to take responsibility for her own aggression without feeling that this made her a ‘bad lot’ or someone not fit to have a life. She also developed a greater capacity to take an interest in other people and began to see her analyst as a human being rather than as ideal or terrifying. She said that she felt that she became a member of the human race rather than remaining as a shadow person. I felt that there was an essentially different quality to her, that her life had become launched and was a going concern rather than an ‘awakening’ that might not last. Despite her remaining difficulties, she no longer seemed under threat as she had done initially. For, as she said, she had to have a life.

Discussion The retreat to an idealised object can entail such severe splitting that the personality is drastically impoverished. Klein describes the introjection of a good object as the basis for normal development, stating that ‘it comes to form a focal point in the ego and makes for cohesiveness of the ego’ (1946: 9). She sees idealisation of the good object as a characteristic feature of the earliest relation to the mother but points out the hazards of excessive splitting. When persecutory fear is too strong, the flight to the idealised object becomes excessive and this severely hampers ego development and disturbs object relations. As a result the ego may be felt to be entirely subservient to and dependent on the internal object – only a shell for it. With an unassimilated idealised object there goes a feeling that the ego has no life and value of its own (p. 9). Clearly, for Miss Y. the problems of assimilation of her objects were immense. Her ego lacked the cohesiveness that is based on the introjection of a good object, instead being tacked together like the griffin. This was related to her flight to an Downloaded by [New York University] at 03:54 14 August 2016 idealised object, often her sister or father, to escape feelings of persecution and damage. Bion’s concept of a split between material and psychical satisfaction has helped me to understand this patient, because he describes a split between two types of functioning as well as between two types of object. Miss Y. retreated to a material relationship to her objects when thought and feelings became too threatening. She came to analysis because she was afraid of dying through ‘starvation of essentials’, both actual food and psychic essentials. My initial feeling of dread at a dutiful analysis was because of the fear that this would be nothing more than a ‘compelled resumption of sucking’, with no hope in it. It was helpful to Aspects of splitting and their relationship to parental losses 207

Miss Y.’s analysis that she was at times well aware that she starved herself of interests and of a capacity to think; she found her retreat stiflingly boring but felt unable to come out of it. A large part of her motivation for getting better consisted in her awareness of the limitations of her retreat and her wish to be able to keep alive feelings of interest in things and people outside herself. Bion suggests two causes of this type of splitting: the role of envy and the fear of aggression, ‘his [the infant’s] own or another’s’ (1962a: 10). Many writers have emphasised the part played by envy and this was clearly an important aspect of Miss Y.’s functioning, particularly with regard to her attacks on gender and generation differences. Miss Y.’s identification with her father obscured the gender difference and her preference for a sister-helper served among other things to obviate the need to accept the generation difference between herself and her parents. However, in the case of Miss Y. I felt that there were other aspects that were just as important as envy, namely her fear of her parents’ internal dead or damaged objects and the part played by her own powerful jealousy as distinct from envy. While patients like Miss Y. are clearly in the grip of something so life-threatening that they may actually kill themselves I felt that in her case it was particularly important to keep an open mind about the location and the nature of the deadly object. At the start of her analysis she was all too ready to see herself as deadly and destructive – ‘a bad lot’ – and it seemed to make a difference to her that I didn’t accept this as the whole picture, which might have been like taking it as read that she was indeed so negative that she could not hope to have a life like other people. It seemed important that I came to understand that there was something deadly inside her object, like the ghosts in the swamp, which threatened her life. Recognition of the ghosts seemed to lessen the feeling of being swamped by negativity and hopelessness, which in turn made it gradually become possible for her to be more aware of the conflict between her positive feelings and her destructive ones. Her responsiveness to her analysis suggests to me that her destructiveness was not the main factor that had driven her to a standstill, but that this had as much to do with her fear of, and identification with, parental damaged objects. Sours (1974) has described how anorexic patients will often have been picked out by the parents as a potential fulfilment of their own aspirations or as a replace- ment for a dead, defective or disappointing sibling. I would also suggest that Downloaded by [New York University] at 03:54 14 August 2016 when the child then cannot fulfil these parental expectations, he or she will be felt to be a failure. An idealised view of the child gives way to disappointment and despair, and the child comes to represent the dead or damaged sibling. The fact that Miss Y. was her parents’ second child, perhaps evoking feelings about their own younger siblings, may have predisposed them to select her for these projections. This leaves us with the question of why this particular child was so sensitive to her parents’ ghosts. Vergopoulo (1986) has described the retreat to autistic manoeuvres in patients who were the eldest or second children in large families where the children were born in quick succession and the parents’ sexuality was 208 Kate Barrows

too much in evidence for the child to bear. She finds that learning difficulties and avoidance of sexuality stem from the child’s inability to tolerate the Oedipal situation and the appearance of siblings both in reality and at a symbolic level. Miss Y.’s hostility and upset about the births of her younger siblings were not worked through, her sister subsequently being idealised while hostile feelings were experienced in relation to other sibling figures. In considering the aetiology of Miss Y.’s difficulties it is hard to know how much is due to her position in her particular family and how much to her innate temperament. Whatever the balance, I think it likely that there was a connection between Miss Y.’s undealt-with jealousy of her younger siblings and her sensitivity to her parents’ internal dead or damaged siblings. She seems to have suffered from hypersensitivity to siblings, her own and her parents’. She was extremely jealous of her siblings and of each parent in relation to the other and it seems likely that jealousy of her parents’ internal as well as external objects may have contributed to her fear of ghosts and the tendency to identify with them. The acute jealousy that she experienced has a different quality to envy, which tends to be more pervasively poisonous and likely to sour the quality of an analysis and to make the analyst feel more thoroughly undermined than was the case with Miss Y. My experience with this patient was of good communication that kept getting destroyed or disrupted. Perhaps this speaks of an infant who could have in some ways a good relationship to her early objects, but only in one-to-one relationships. Over the past twenty years or so much attention has been paid to the analyst’s countertransference feelings about the patient, and the ways in which the patient relates to the analyst’s internal objects. Clearly, this originates in large measure in the child’s relationship to his or her parents’ internal objects and to the parents’ relationships to these objects. It could be said that the infant’s earliest introjects are, in fact, his parents’ internal objects. Thus we find that a patient whose parents have particular kinds of internal objects – inadequately mourned siblings in this instance – will be aware of these and possibly identify with them. The split between material and psychic seems to have served the purpose of protecting Miss Y. from these terrifying objects, the ghosts inside her parents compounded with her own projections. The difficulty for this sort of patient in Downloaded by [New York University] at 03:54 14 August 2016 feeling that they can have any sort of life or character of their own seems to be a significant factor in their withdrawal. It was an important moment for Miss Y. when after three years of analysis she said that she was beginning to feel that she had a personality.

Note 1. First published in 1999 in the International Journal of Psychoanalysis, 80: 549–61. References

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absent third object 140 analyst/mother 111, 139, 186, 189 abstract thinking 127 analysts: idealisation of 134; non-sexual acceleration anxiety 145 perverse relationships with 193n9; activity 142 phantasies of living inside 141; taking in adhesive equation 13, 107, 109, 110, of transference elements 129–30, 187, 167, 177 188; triumph over xxxvi; use of as a adhesive identification 13, 62, 63, 65, 88, second skin or container 169; utilization 107, 109, 132, 137, 141, 167 of, for sensations engendered by 177 adhesive identity 13, 62, 63, 65–6 analysts’ voice 139, 141, 183 adhesive pathology 13–15, 63, 65–6 analytic breast 186 adhesive position 62 analytic interpretation xxxv, xxxvi adhesive sameness 47 Andersen, J. 6, 97 adhesive unity 13 animal sounds 47 adhesive-at-oneness 13, 14, 42, 46, 52 annihilation: and autistic retreat 53; adolescence 132, 146, 149 breakdown of mother-child unity and adults: bodily experiences in analysis of 59; terror of 45; human contact experienced precipitation anxiety in analysis of as 35; loss of communication and threat 143–54, see also autistic states in adults of 64; paranoid-schizoid anxiety and aesthetic conflict98 , 151–2 impending 165; of voices, in non- aesthetic moment 63 communication 47 aesthetic object 62, 151–2 annihilation anxiety 116, 117, 118, 128, aesthetic reciprocity 151, 152 129, 130, 131, 145 aetiology (child psychosis) xxix–xxxi, 3–12 anorexics 66, 100, 111–12, 113–14, 207 age 71 Anthony 101–14 agency 77 Anthony, J. 155 aggression 44, 47, 65, 98, 99, 110, 111, anti-social tendency 93 121, 140, 207 anxiety(ies): about falling 118–19;

Downloaded by [New York University] at 03:54 14 August 2016 aggressive play 78 about incest 140; adhesive equation Aitken, K.J. 78 and perpetuation of 110; bodily 61, alcohol abuse 113 66, 110; infant/child as container for alpha function 78, 86, 109 parents’ 112, 141, 199; liquid states and alter ego 27 evocation of 22, 24; looking as a source Alvarez, A. 11, 84 of 96–7; in the object-related and autistic anal masturbation 60 states 177; of separation 26, 51, 138–9, analysis: autistic states in adults 174–93; 147; and tactile sensation 48, see also learning from experience 184–5, 188; annihilation anxiety; autistic-contiguous recognition of encapsulation and length anxiety; precipitation anxiety of 142; rumination and imitation as Anzieu, D. 66, 155 substitute for 162 Arielle 58–9 Index 223

asceticism 199 autistic objects 159; distinguished from Asperger, H. 83 ordinary and transitional objects Asperger’s syndrome: definition of 83; 192n5; familiarity with concept of observation in psychoanalytic treatment 175; hallucination sustained by 65; 83–99 idiosyncratic use of xxvi, 182–4; assault objects 19 pathological autism 161, 162; as Association of Child Psychotherapists 3, 10 substitute for healing relationship 160, associations: neurotic patients 136, 138 see also bottle breast/sippy cup asymbolic experience 161 autistic retreat 37, 38, 41, 42, 52, 53 asymbolic state 41 autistic shapes 158–9; distinguished from at-one-ment xxxii, 175, 177, 183, 186 normal shapes xxvii; distinguished from at-oneness 5, 12, 13, 14, 42, 43, 52, 65, 88 objective shapes 192n5; familiarity with atavistic instinctual elements: projection of concept of 175; pathological autism predatory forms of 64 161, 162; self-soothing use of 166; attachment 202; to the therapist 99 sensation of at-one-ment 186; use of attention 71; capacity for 83–4; fixation on odor as 160 sensation-objects and sensation-shapes autistic shell 4, 50, 54, 84, 152, 197 185, see also joint attention autistic states in adults 174–93; analysis atypical children xxiii setting 179; analysis (vignettes) 180–2; auditory capacity xxiv detecting 176; differential diagnosis auditory sensations 40, 41, 53 176–8; dread of dissolution 187–90; Audrey 181 idiosyncratic use of objects 182–4; Auina 59 motivation 184–5; neurotic patients autism: intra-personal view 70; normal 134–54; the object in the periphery 173n1; prenatal trauma and 37–53, see 185–8; resistance and collusion in also autistic states in adults; childhood analyst and analysand 190–1; those autism; infantile autism; pathological who have ‘lingered in the chambers of autism the sea’ 178–9 Autism and Childhood Psychosis xxii, 5 autoeroticism 4, 61, 63, 67 Autism Workshop 73 autosensual protections 12, 62, 182–4, Autistic Barriers in Neurotic Patients 5, 37 187, 188 autistic children: avoidance in looking autosensuality xxvii, 173n1, 175 at people 39; body image and aversion reactions (prenatal) 37, 41, 51 identity 100–14; clinical material 12; avoidance of pain 141 communication see communication; avoidant behaviour 188 mothers of see mothers; pain of trauma 16; recognition of separability the back, the background: the gaze and the as impossible 153; use of ordinary skin 55–8 objects 182, see also childhood autism; background object 59, 61, 63 confusional child; encapsulated child background place 55 autistic contiguous anxiety 165–6; and the background presence 61–2, 67 Downloaded by [New York University] at 03:54 14 August 2016 binding power of symbols 170–2 background of safety 62 autistic contiguous position 155–73; bad object(s) xxxiv, 32, 53, 60 defences 166–8; internalization in Balint, M. xxix 168–70; nature of sensation-dominated Barrows, P. 78, 101, 108, 113 experience 157–60; pathological autism basic fault xxix 160–5; prenatal life 40; primitive bedwetting 46–7 organization of experience 156–7 Begoin, J. 152 autistic defences xxx; autistic-contiguous Berenson, B. 63 166–8; as avoidance of pain 141; Bettleheim, B. xxvi, 193n10 and the experience of premature Bibring, E. xxix, 10 birth 19–36 Bick, E. xxii, xxiii, xxiv, xxxi, 13, 54, 62, autistic maneuvers xxiv, xxxii, xxxiv, 207 107, 137, 155, 167 224 Index

biochemical assault 39 of nipple from 140; fear of death/ Bion, W.R. xxii, xxxi, xxxii, xxxiv, 11, 16, disintegration caused by absence of 24, 43, 54, 62, 70, 78, 86, 97, 107, 108, containing 141; ‘good and sweet’ 95; 109, 134, 140, 145, 155, 187, 188, 195, integration of ‘good’ and ‘bad’ 93; 206, 207 prenatal auditory experience and non- birth see physical birth; premature birth; recognition of 41; sensorial illusion of psychological birth continuity between mouth and xxii–xxiii; black hole xxxiv, 153 sensory integration of nipple, tongue ‘black hole with a nasty prick’ xxix–xxx, and xxxii, see also ‘black hole with a xxxiii, 8, 9, 152, 178 nasty prick’; broken breast; firework ‘black-hole’ type depression 10, 11, 15, 123 breast; nipple; ‘sippy cup and bottle/ bodily anxieties 61, 66, 110 breast’ routine bodily cohesion 166 bricks collapsing: insecurity felt in terms bodily integrity 61, 110, 113 of 106, 135–6 bodily separateness 65; adhesive identity Britton, R. 109 62; avoidance of unbearable awareness broken breast 7 of xxiv; infantile trauma xxix, 12–13, broken mouth 102, 152 14–15, 38, 102; premature awareness Bruner, J.S. 72 xxx, xxxiii, 152, 153, see also ‘two Bruno 55–6 halves of the body’ bulimia 101, 108, 113, 199 body: anorexics and preoccupation with Burhouse, A. 72 space 100; autistic experiences 59; cathexis 58, 61; closed system 161; caesura of birth 143, 144, 145 expressive gestures 71; image, and Cambier, J. 129 identity 100–14; loss experienced in terms A Case of Hysteria 140 of xxix; memories 35; mutilation 103; Cassidy, S. 15 phantasies 20, 60; signs, and awareness castration phantasy 58 of separateness 186; softness 65; unity of catastrophic anxiety 152 mind and 133; use of as a container 139, catastrophic birth experience xxxi, 101–2, see also ‘two halves of the body’ 113, 152–3 body countertransference 87 catastrophic depression 11 body ego 54–68, 88, 156; clinical material catastrophic lack 64 55–61; theoretical considerations 61–7 cathexes 116, 129, see also body cathexis; bonding xxxiii, 14 libidinal cathexis Botella, C. 66 cement-semen association 106, 136 bottle breast/sippy cup 24–5, 26, 27, 30, cerebellar abnormality 128–9 31, 33 cerebellar atrophy 116 bottle refusal 44 cerebellum 115, 116 bottom floor 56, 58, 64 cervical ring 42, 43, 46, 50 ‘boucle de retour’ 54 Cesbron, M. 57 boundary(ies): challenging of analytic chasmic mother 16 Downloaded by [New York University] at 03:54 14 August 2016 184; preoccupation with the skin as child(ren): idealised view of 207; as 100; primary 65; sense of 61; tactile receptacle for parents’ internal objects sensations and bodily 19, 40 199, see also autistic children; fragile boundedness 157–8, 160, 165, 170, 172 child Bower, T.G.R. 155 childhood autism: adhesive pathology Bowlby, J. xxii, xxiii 13–15; clinical material 12; effect of Brad 181 modified view15 –16; normal infancy Bradley, N. 140 and pathological developments 12–13; brain 115 regression hypothesis 3–12 Brazelton, T.B. 155 childhood psychosis (Tustin’s work): breast: autoeroticism 61; with a broken applications xxxviii; developmental nipple fantasy 152; differentiation model xxxi–xxxiv; diagnostic Index 225

classification xxvii–xxix; etiological containment; mental containment; considerations xxix–xxxi; observation physical containment; verbal containment and theory xxiv–xxvi; patient contexts (language) 72 population xxiii–xxiv; recommendations control 32, 43, 181 for treatment xxxiv–xxxviii cork child 16 Clarke, D.F. 69 Corominas, J. 88 clinical intuition 73–4 corporeal collapse 178 clustering (verbal) 47 counter-transference 47, 51, 73, 75–6, 94, cognitive defect 11 124, 130, 186, 205 cognitive development 116 Courchesne 115 cohesion of self: attempt to repair a Creak, M. xxiii–xxiv failing sense of 160; autistic shape and creativity 94 sense of 158; imitation as a means of cruelty: of the impervious combined object achieving 169 102–4; as re-enactment of catastrophic coincidence of vulnerability 190–1, 193n10 birth experience 101–2 coldness xxxiv, 53, 158 ‘crustacean’ children 54 collapse: absence of object and crustaceans: appearance in dreams of 107; awareness of separateness neurotic patients 135 and 177, 178; into catastrophic crying 45, 102 depression 11; of normal routes for Cyclops effect 55, 56 development of symbolic thought 21; cystic encapsulation 134, 191n3, 197 psychopathological 170, 171 cystic swellings 140 collusion (analyst/analysand) 190–1 combined object 59, 95, 107; cruelty of the damaged objects 59, 104, 108, 109, 110, impervious 102–4 194, 203, 207 commensal relationships 109 David xxvi, 104 common sense 84, 97 deadlines 168 communication 69–79; imaginary friend death 122; fear of 86, 122–3, 141 94–5; normal infant development 71–2; death instinct 144, 196 therapeutic implications of impairments delinquent adolescent-like acts: and relief 73–9; of trauma 102; trauma from oppressive guilt 92 ‘flashback’ as 15, see also facilitated denial 43, 113, 134–5, 136, 177, 178 communication; language; non-verbal dependency 177, 178, 183 communication; voice depersonalization 64 compulsive behaviour 135, 164–5, 168, 176 depressed mother(s) 13, 16–17, 38, 39, concrete thinking 140, 197 41, 153 conflict dynamics 150, 154 depression: hyperactivity and protection confusional child xxiv–xxv, xxvii–xxviii, from 131; manifested through the xxx, 20 body 129; working through 124–6, confusional objects xxv see also ‘black-hole’ type depression; confusional tendencies (maternal) xxxiii catastrophic depression; maternal Downloaded by [New York University] at 03:54 14 August 2016 Connie 182 depression; primal depression; primary conscious phantasy 168 depression; psychotic depression constancy 182 depressive position 62, 122, 132, 155, 156, container: and contained relationship, 157, 159, 165, 170, 171, 172 reversal of 198–9; use of analyst as a deprivation 93, 112 second 169; use of body as 139; use of destructive behaviour 101, 121 infant as 112, 141, 199 The development of I-ness 54 containing function 45, 54, 58, 66 developmental psychology 53, 71 containment 155; dread due to a lack of developmental research 74 adequate 86; primal depression and 11; developmental thinking 78 sensory-mental-bodily 88–9, 164–5, deviant personalities 73 see also emotional containment; maternal diabolon 131 226 Index

diagnostic classification xxvii–xxix encapsulated happenings 176 differential diagnosis 176–8 encapsulation xxxi, xxxiii, xxxiv, 192n7; differentiation 131 cystic 134, 191n3, 197; dimensionality discomfort sensations 64–5 xxxix; global and segmented xxviii, 54; disconnectedness 157, 160, 165, 171, 172 loosening of protective wraps 188; of disintegration xxxi, 139, 141, 165, 167, 177 personality, recognition of, and length dismantling 83, 129 of analysis 142; as a psycho-physical dismemberment (fear of) 103 protective reaction 37 dissociative state 192n7 encystment 140 dissolution 172, 177, 186, 187–90 energy gradient 143, 144–5 dread(s): deadness of the autistic shell as entangling (autistic) xxiii, xxiv, xxx, xxxii a protection against archaic xxxiv; of entrapment xxvii, 170, 171 dissolution 187–90; diverting awareness environmental mother 62 away from unthinkable xxx; due to envy xxiii, 186, 197, 207, 208 lack of adequate containment 86; of epistomophilic drives 151 separateness, analysts acknowledgement eroticism 66, 131, see also autoeroticism of 186–7 Europe 3, 83 dream material 59 excorporation 65 dream screen 62 existential terrors 111, 175 dream-life 24 experience(s): analysis and learning dream-thoughts 130 from 184–5, 188; nature of sensation- dual track 13, 62, 63 dominated 157–60; primitive organization dual unity 5, 12, 13, 17, 42 of 156–7; shaping of the brain 115 dyadic competence 72 expressive bodily gestures 71 external object(s): anxiety through lack ear 40 of secure 203; caesura of birth and eating: anorexic patients’ fear of 113–14; 145; containing 62; excorporation and confused with separating a parental 65; jealousy of parental, and fear of couple 107–8; confusion between ghosts 208; pathology and lack of 63; sexual maturity and 100; disorders psychological change arising from 111–13, see also food experience of 168; relatedness 158, 173n7 echolalia 44, 46, 47, 62, 169, 186 ‘extra bit’ xxvi, 104 ecstasy 62; of at-one-ment xxxii, 175, 177, eye contact xxiv, 55, 57, 58, 63, 74, 76, 183; origin of term 193n8 97–8, 167 egg metaphors 4 eyes 71–2; of the confusional child xxiv; ego: introjection of good object and inability to recognise complex images cohesiveness of 206; in object-related 129, see also gaze; looking; vision and autistic states 177, see also alter ego; body ego; superego face-to-face dyadic mutual gazing 72 ego ideal 62 face-to-face interpersonal communication Eimas, P. 155 71, 74 Downloaded by [New York University] at 03:54 14 August 2016 elbow 61 the Face: tripartite structure of 105–7, 108, elective mutism 85 109 emotional adhesiveness 63 facilitated communication 6, 11 emotional communication 71 Fairbairn, W.R.D. 155 emotional containment 20, 52, 78, 102 falling 32 emotional engagement 71 falling down 50, 110, 116, 118–19, 120, emotional events 72 128, 147 empathy 14 falling infinitely/endlessly xxx, xxxiii, 11, emptiness 17, 43, 141, 178 62, 63, 66, 165 ‘empty fortress’ xxvi, 193n10 falling out of control 177, 178, 180, 181 encapsulated child xxiv, xxv–xxvi, xxx, false self 134, 169 27, 54, 58, 84 fantasy play xxvi, 22, 26 Index 227

fantasy representations 130 gaze/attention 54–5, 66 Fatemi, S.H. 116 general knowledge (analysts) 185 father: as aggressive masculine nipple 140; genetic anomalies 116 idealised 195; identification with 33, 77 Georgette 100, 111–12 father-figure95 , 105, 106, 109, 117, 147, 148 gestural production 116 fatherese 74, 77 ‘ghosts in the nursery’ 194; and split fear(s): of aggression, as a cause of between the ‘psychic’ and the ‘material’ splitting 207; of being dismembered/ 195–208 disjointed 103; of death 86, 122–3, Gillette, E. 4–5 141; of eating 113–14; of loss of feces global type encapsulation xxviii 120–1; reaction 13 going-on-being 14, 49, 50, 158, 189 feeding situations: bodily resonance with ‘gone forever’ experience 65 60; coordination of senses 97; infantile good baby/child 188 rumination 162 good and bad/sweet breast 93, 95 feelings: analysis and release of explosive good enough mother/mothering xxxii, 86, 93 179; of silent patient, learning to good feeding situation 97 understand 141 good object(s) 32, 53, 93, 140, 206 felt shapes 157–8 gradient dynamics 143–4, 144–5, 150–1, fetal reactions 39 154 firework breast8 ‘gradient of the unknown’ 151 first theory of instincts 150 Green, A. xxxiv, 64, 65 flop-type depression 11 Greenacre, P. 62 flowing-over-at-oneness12 , 65, 88 Greene, G. 175 Fonagy, P. 194, 202 grief: object loss and emergence of xxix food: confused with rival babies 100, Grotstein, J.S. 13, 39, 56, 61, 62, 63, 67 112, 113 guilt 91, 119, 130, 132, 140 Fordham, M. 3, 155 fragile child 146, 149 hallucinations 8, 64, 65, 181 fragile mother 139, 205 Hamilton, V. 4 fragmentation (sensory) 140 hands 61, 67 Fraiberg, S.H. 109, 112, 194 hard objects xxvi, xxx free associations 131 hard sensations xxxi, xxxii, 26 freezing xxxiii, 38, 178 hardness xxx, xxxii, 57, 64, 158, 160 Freud, A. 199 Harris, M. xxii, 98 Freud, S. xxix, 4, 5, 61, 92, 110, 140, head banging 160, 166, 176 144, 150 head/trunk junction 61 Freudians xxi, 5 hearing see auditory sensations fringe awareness 12, 185 helplessness xxx, xxxii, 10, 38, 41, 100, Frith, U. 14 142, 181, 183 frozen child 14, 53 Hermann, I. 65 frozen infant 13 hidden capsule 174 Downloaded by [New York University] at 03:54 14 August 2016 frustration xxxiii, 78, 112, 121 hide and seek 29–30 functional disorders 128, 129, 133 historicity 170, 171 functional object 27 holding 67, 97 Furer, M. 5, 155 Homage to Frances Tustin 64 Hopkins, J. 16 Gaddini, E. 62, 155 horizontal splitting 60–1 Gaddini, R. 155 horse-grass-shadow 108, 109, 110 Garreau, B. 116 hospitalization (trauma of) 21, 36, 146, gaze: aversion 21, 42; the back, the 149–50 background and the skin 55–8; hostility 106, 134, 136, 137, 139, 140, 208 emotional communication 71; of Houzel, D. 17, 118 encapsulated child xxvi; monitoring 72 hypersensitivity xxxvi, 21, 99, 102, 197, 208 228 Index

hypertrophic speech 141 infantile trauma 175; bodily separateness hypotonia 116, 120, 128 and xxix, xxx, 12–13, 14–15, 38; hysteria 61, 138 re-enactment 6, 14, 15, 50 innate preconceptions 62 I-ness 54, 157 inscription: of memory traces 133 idealisation 130, 134, 194, 195, 205, 206, insecure mental containment 13 207, 208 insecurity: felt in terms of bricks idealised retreat 194, 206 collapsing 106, 135–6 identification: with the father 33, 77; inside/outside 20, 35, 40 processes of 14; and tolerance of loss insomnia 165 of self 62–3; vampire-like 117, see also integrity: of self 107, 166, 167, see also adhesive identification; introjective bodily integrity identification; primary identification; inter-psychic mobility 131 projective identification; pseudo- interest 71 identification internal object(s) 59, 70, 102, 130, 155; identity: body image and 100–14; anxiety through lack of secure 203; identification and 14, see also badness of 53; ‘jungle voice’ as a self-identity container of 52; miscarriages as the ideographs 140 realization of non-containing 51; illusion (autoerotic) 61, 63 phantasies of projection of aggressive imaginary friend 94–5 feelings into 140; pseudo-identification imaginary other 25 with parental 132; relational continuity imaginary twin 43, 108 with 145; working through 124–6, imagination xxxii, 20, 84, 177 see also ‘ghosts in the nursery’ imitation 62, 162, 167, 169–70 internalisation 71; in the autistic immobility of objects 44 contiguous position 168–70 impervious combined object 102–4 International Journal of Psycho-Analysis 3 ‘impinged’ separateness 185, 186 interpretation (analytic) xxxv, xxxvi imprinting 19, 20, 55, 58, 66 intra-psychic mobility 131 inappropriate behaviour 83 introjection 14, 61–3, 71, 88, 119 inborn unresponsiveness 4 introjective identification 135, 141, 167 incest 140 intrusive identification xxxvi, 65 ‘incubator’ role 90 Isaacs, S. 67–8 Independents xxi, xxiii isolated child 41, 44, 84, 98 individual psychotherapy 132 isolation 38, 41, 77, 157, 192n7, 201 individuation 14, 61, 150 infant(s): awareness of thinking 61; jealousy 136, 137, 208 confusion between food and rival Jerome 146–51 100, 112, 113; as container for John xxix–xxx, xxxi, xxxiii, 6–12, 13, maternal projections 112, 141, 199; 14–15, 17, 64, 104

Downloaded by [New York University] at 03:54 14 August 2016 inborn unresponsiveness 4; normal Johnny 83–99 development 4, 39, 40, 71–2; pathological joint attention 74, 77 developments 12–15; understanding of joints (limb) 61 maternal unavailability 95 Joseph 74–7 infant-self: fear of the analyst coming in The Journal of the American contact with 189 Psychoanalytic Association 4 infantile amnesia 132 Julia 189 infantile autism: with cerebellar anomaly, jungle voice (Rosetta’s) 47, 49, 51, 52 long-term mother-child psychotherapy 115–33; extreme 157 Kandel, E. 115 infantile rumination 161, 162 Kanner, L. xxiii, 52, 53, 83, 155, 193n10 infantile transference 7, 15, 179, 190 Kanner-type autism xxviii, 6, 57 Index 229

Karen 182–4 Lucie 180–1 Klein, M. (Melanie) xxiii, 65, 71, 93, 104, Lyth, O. xxii 140, 144, 155, 156, 177, 185, 206 Klein, M. (Milton) 4–5 McDougall, J. 16, 66, 100, 111 Klein, S. 106, 155, 191n3, 197 MacLeod, S. 100, 112 Kleinians xxi, xxii, xxiii, xxxvi, 9 Madonna and Child sculpture 16–17 knee 61 Magnana, J. 17 Mahler, M. xxiii, xxiv, xxix, 4, 5, 9, 10, 155 language: anxiety of separateness and effect Maldiney, H. 62 on 46; cerebellar pathology and 116; Mancia, M. 52 of confusional child xxii; contexts 72; manic denial 177, 178 triadic skills and visual regard 72, manic patients 141 see also proto-language Martine 116–33 lateral object of primary identification mask-like expressions 44, 46 58–60, 67 massive projective identification xxxi, 66 Laurent 56–7, 65 masturbation 60, 168, 183 Le Corps et Le Sens 129 materialism of sense impressions 199–200 Lechevalier, B. 129 maternal body: consulting rooms equated Leonard 189–90 with 179 Leslie xxviii maternal care 86 libidinal cathexis 131 maternal containment xxxii, 78, 102, 188 life instinct 144 maternal depression 52, see also depressed lifegiver 16 mother(s); postnatal depression; Limentani, A. 141 prenatal depression links 66, 109, 148 maternal distress 41, 53 liquefaction 24, 26, 62, 63, 66 maternal object 41, 123 liquid states/liquidity 22, 24, 38, 44–5, 54, maternal personality 52 178, 187 maternal pole of object relations 150 listening 40, 69, 70 maternal voice 39, 40, 41, 52, 53 Live Company 11 Mathew, M.A.F. 88 lived experience 170 me/not me xxxi, xxxiv, 65 loneliness 17, 59 meltdowns 179 ‘long-distance’ mode of perception 40, 41 Meltzer, D. xxii, xxiii, xxiv, xxviii, 9, 13, long-term memory 115 52, 62, 83, 86, 98, 101, 107, 114, 132, long-term mother-child psychotherapy 140, 143, 151, 152, 155, 167 115–33 Memorial Tribute to Frances Tustin 64 looking 96–7 memory 35, 51, 63, 115, 133, 145 loss: adhesive pathology 13; and anti-social mental containment 13, 34, 50 tendencies 93; experienced in terms mental development xxxii, 52 of the mouth xxix–xxx; of feces, fear mental growth 145, 150

Downloaded by [New York University] at 03:54 14 August 2016 of 120–1; of ‘mouth-tongue-nipple- mental uterus 102 breast’ continuity 152; of object, and mentalized anxieties 61 emergence of grief xxix; of object, and mentalized ego 61 primal depression 10; of odor, as a loss mercyism 161, 162 of self 160; reaction to, in object-related metabolon 131 and autistic states 177; in the sensation- metaphors: for pathology of autism 4 ego 64–6; of a sense of self 63 Miller, L. 3 love object 10, 65 Milner, M. 62–3, 155 The Lovely Bones 178–9 mimicry 167 loving looks 97–9 mind: alpha function 78; consequences low self-esteem 83, 86 of intrusion of caregiver’s damaged lower limbs 60–1 experiences on child’s 194–5; relation 230 Index

to/with internal objects 70; sensations as mutual cannibalism 108, 112 foundation of xxxii; state of, following mutually destructive relationships 112 early catastrophe xxxi; unity of body and 133, see also maternal voice-mind; nameless dread 86, 187 postnatal breast-mind; theory of mind narcissism 4, 130, 151 mindfulness 22, 132 naturalistic observation 73 mindlessness 11 neck joint 61 mirroring 95, 107, 109, 113 negative hallucination 64 misanthropy 197 neurotic patients: autistic phenomena in miscarriages 38–9, 42, 50, 51 134–54 Miss Y. 195–206, 207–8 nipple: confusion of penis and 140; Mitrani, J.L. 64 differentiation from breast 140; Mitrani, T. 64, 193n8 experience of aggressive masculine moods: of silent patients, learning to 140; failed cooperation between mouth understand 141 and xxxiii; failure of commensal Moore, H. 16 relationship and fight over109 ; fear of mother-child psychotherapy 115–33 death/disintegration caused by absence mother-child relationship 52, 151, 155 of containing 141; loss of continuity mother-figure 102, 103, 104, 106, 109, between tongue, mouth and 152; sensory 112, 113, 123, 126 integration of tongue, breast and xxxii mother-infant 158 nipple-penis: reciprocal gaze, verticality motherese 74, 77 and 55 mother(s): of autistic adult patients 188; ‘no-distance’ sensations 40, 47, 53 of autistic children 84, 193n10; autistic no-thing xxxiv shapes as substitute for 162; confusional nocturnal enuresis 46–7 tendencies in xxxiii; as functional object non-communication 47, 141 27; fused, undifferentiated situation ‘non-entry’ defence 112, 198–9 with 12; infant communication with 63; non-existence 141 and neurotic patients’ psychosomatic non-object relatedness 4 symptoms 139; ‘reverie’ function 187– ‘non-person’ feeling 12 8; separateness from see separateness; non-sexual perverse relationships 193n9 ‘shock absorber’ function 86, see also non-verbal communication 47, 71, 109, analyst/mother; depressed mother(s); 130, 190 environmental mother; good enough ‘normal adhesive component of group mother/mothering; refrigerator mothers envelopes’ 62 motility (fetal) 40 normal adhesive identity see massive motivation 184, 186 projective identification motor function 116, 129 normal adhesiveness 63 mouth: failed cooperation between nipple normal autism 173n1 and xxxiii; loss of continuity between normal infant development 4, 39, 40, 71–2 tongue-nipple-breast and 152; loss normal projective identification xxxii, 65, 188 Downloaded by [New York University] at 03:54 14 August 2016 experienced in terms of xxix–xxx; normal shapes xxvii sensorial illusion of continuity between normal states: oscillation of 13, 14 breast and xxii–xxiii ‘not there’ experience 64, 65 Mr D 171 ‘not-me’ experiences xxxi, xxxiv, 65 Mrs M 162–4 nothingness xxxiii, 147, 177, 178, 187, 188 Mrs Pick xxv Mrs R 167–8 object(s): childhood autism xxv, xxvi, mute autistic child xxvi, 11, 85, 141 xxx; equations between self and 107; mutilation: of the impervious combined idealised 194, 206; immobility of object 102, 103, see also self-mutilation 44; loss see loss; mutual antagonism mutual antagonism: between non-identical between non-identical 108; self and see objects 108 self and object, see also aesthetic object; Index 231

autistic objects; bad object(s); damaged parents: experienced as an impervious objects; external object(s); functional combined object 102–4; sexuality of, as object; good object(s); internal overwhelming 207–8, see also father; object(s); sound-object mother object constancy 62 part-objects 31, 67, 90, 91, 95, 105, 129, object permanence 116 140, 197 object relations 84; gradient dynamics passive primary unintegration 177 144–5, 150–1; imitation and 169; passivity 142 phantasized 162; sensation-dominated paternal pole of object relations 150 experiences 157, 158; theory 155, 172, paternal quality 67 see also non-object relatedness paternal transference 117, 131 object-related state 176–7, 178 pathological autism 64–6; autistic contiguous object-representations 62 experience 160–5; imitation in 169; as a objectless ‘self-sufficiency’ 162 regression see regression hypothesis oblique communication 85 pathological developments: normal observation: in psychoanalytic treatment of infantile situations 12–15 Asperger’s syndrome 83–99 pathological projective identification see observer 24 intrusive projective identification obsessional behaviour 132, 135, 164–5 patient therapeutic material: as theatrical odor: use as an autistic shape 160 representation of the inner world 154 Oedipus complex 73, 131, 132; child’s Paul 57, 58 inability to tolerate 208; closure of triangle peek-a-boo game 96, 97, 117 experienced as disaster 109; conflicts peer relationships 83 132; deprivation 112; drama 32; guilt penis 55, 140 feelings 130; object relations and mental perception xxviii, 20, 40, 158 functioning 150–1; rivalries 77; scenarios, Perez-Sanchez, M. 3 using dolls for 122; triumph 119 peripheral vision 185 Ogden, T. 40, 56 persecutory feelings 91, 92, 134–5, 206 Oliver, M. 174, 175 personality: cult of, in analysis 5; omnipotence xxxvi, 77, 78, 142, 178 exacerbation of autism 73; making omnipotent appropriation 106, 135 contact with non-psychotic part of 70; On Mahler’s Autistic and Symbiotic maternal 52; neurotic patients 134, 135; Phases 4 recognition of encapsulation, and length one-dimensionality 20, 21 of analysis 142 one-person psychology 70 Pessoa, F. 69 ontogenetic defences of the organism 62 Peter xxvi, xxxvi–xxxvii, 104 opposites 175–6 Peterfreund, E. 5 oral aggression 47, 110, 111 phantasies: of being unborn and living inside oral gratification95 analyst 141; bodily 20, 60; paralyzed oral sadism 66 xxxix; of projection of aggressive feelings oscillation 13, 14, 142, 177 into nipple/breast 140; of repossessing Downloaded by [New York University] at 03:54 14 August 2016 osmotic pressure (prenatal) 38, 50 the other 60; sexual 138, 168, see also other/otherness 51, 60, 95, 131, 145, 159, castration phantasy; twinning phantasies; 162, 177, 183, 187 unconscious phantasy overeating 113 phantasy objects 104 physical birth: as a psychological pain: avoidance of 141; expressing 119–20, catastrophe 102 120–1; of separateness, analysts physical containment 44–5 acknowledgement of 186–7; of trauma 16 physical intervention xxxv panic 100; awareness of bodily separateness Piontelli, A. 3, 39, 51 and 13; tactile sensations and 45–6 plastic images 67 paranoid-schizoid position 62, 142, 155, play(ing) xxvi; aggressive 78; with the 156, 157, 159, 165, 170, 172 hands 67; shared 74; symbolic 78, 232 Index

see also fantasy play; pretend play; projectile vomiting 85, 86 psychodrama play projection(s) 14, 27, 88; expressing 119; Playing and Reality 147 infant as a receptacle for maternal 112, pleasure principle 196 199; infant-mother 86; ‘overflowing’ as a polysensoriality 118, 129 precursor mechanism to 65; of predatory positive hallucination 64, 65 forms of atavistic instinctual elements possessiveness 138 64; of the sensory apparatus 140–1 post-traumatic stress disorder: infantile projective field 65 version 13 projective identification xxxvi, 9, 27, 63, postnatal behaviour (child’s) 39, 51, 52 66, 71, 88, 135, 141, 155, 160, 167, 169, postnatal breast-mind 53 176, 177, see also intrusive projective postnatal depression xxiii, 153 identification; massive projective postnatal maternal object 41 identification; normal projective potency 77 identification potential space 161 protective reactions 12, 37, 38, 51, 52, 84, pre-auditory phase 140 197, see also autosensual protections pre-symbolic realm 160–1 proto-communication 77 precipitation anxiety 143–54; and the proto-declarative pointing 72 aesthetic conflict 151–2; clinical proto-introjective experiences 40 illustration 146–51; personal hypothesis proto-language 71–2 144–6; and premature psychological proto-sense of person 71 birth 152–3 proto-speech 77 Preconscious 131 proto-theory of mind 71 premature awareness: bodily separateness protomental activity 37, 39, 40, 41, 53 xxx, xxxiii protomental filter41 premature birth: autistic defences and the protomental nucleus 52 experience of 19–36 pseudo-identification 131, 132 premature psychological birth: psychic birth 14 precipitation anxiety and 152–3 psychic catastrophe 15, 16 prenatal depression xxiii psychic development 38 prenatal memory 63 psychic floor 56 prenatal trauma 37–53 psychic forces 133 pretend play xxvi, 74–5, 77, 126 psychic opportunity 15, 16 primal depression xxix, 10, 11 psychic retreat 197 Primal Depression in Autism 11 psychic skin xxxi, xxxiii, 65 primary boundary 65 psychoanalysis: cult of personality in 5; primary confusional syndrome xxviii impairments in communication 73; primary depression 128 loyalty to Freud as an obstacle to progress primary envy xxiii in 5; use of observation in the treatment primary identification 58–60, 61, 67 12-year old boy with AS 84–99 primary intersubjectivity 37, 74 psychoanalysts: acceptability of regression Downloaded by [New York University] at 03:54 14 August 2016 primary narcissism 4 hypothesis 4 primary nocturnal enuresis 46–7 psychobiological autism 37 primary self 3 psychodrama play 126 primary sound-object 48–50 psychogenic autism xxiv, xxix, 37 primary union 88 psychological birth: as a psychological primitive destructiveness xxiii catastrophe 113, 152–3 primitive imitation 62 Psychological Birth and Psychological primitive organization of experience 156–7 Catastrophe xxxi, 101–2 primordial terrors 175 psychological catastrophes xxxii private/personal space 128, 130, 132 psychological prem 90 proactive intrapsychic modifications 130 psychomotor symptoms 55 procrastination: anxiety-producing 168 psychopathology 73, 170 Index 233

psychophysical closeness 52 Rosetta 41–52 psychophysical reactions xxxi, xxxiv, 37, rumination 161, 162 38–9, 50 Rustin, M. 3, 94 psychosomatic symptoms 135, 139 psychotherapy: Asperger syndrome and Sacks, O. 200 psychoanalytic 84–99; impairments safe distance/space 99 of communication 73–4; long-term Salo, F.T. 78 mother-child 115–33; returning loop 54 Sam 21–35 psychotic depression xxix, 10, 11 sameness 43, 47, 175 psychotic islands 134 Sander, L. 155 Putnam Center xxii, 10 Sandler, J. 62 Scaife, M. 72 re-enactment of trauma 6, 14, 15, 16, 50, schizophrenic-like child xxiii, xxv 101–2 Schore, A. 71 re-experience of terrors 50 Scott, C. 67–8 reactive depression 10 screaming/fits 6, 8, 49, 121 reality xxxii, 43 Sebold, A. 178–9 reciprocal gazes 55 ‘second skin formation’ xxxi, xxxvi, 167 reciprocity 47, 53, 131, 151, 152 second theory of the instincts 144 reclamation 78 secondary confusional syndrome xxviii red button 6, 8, 9, 13, 104 secondary intersubjectivity 74 refrigerator mothers 52, 53 segmented encapsulation xxviii, xxxi, 54 regression 14, 26 self: infant’s sealing off, of the nascent regression hypothesis, childhood autism 188; joints as representing 61; loss 3–4; clinical discussion 9–12; clinical of odor as loss of 160; and other, material 5–9; history of the error 4–5 undifferentiation of 51, see also regression therapy 14 cohesion of self; false self; infant-self; regressive movements 130 primary self; sense of self Reid, S. 84 self and object: awareness of physical relational continuity 145 separation between 153; beauty of the reliance on analyst 178 encounter with 152; equations between repetitive behaviours xxvii, xxxiv, 23, 27, 107; self-as-object 157; successful 28, 73, 75, 77, 78, 135, 144, 169, 176 communication between 145 representation 67, 131 self-identity 132 representational models 70 self-mutilation 62, 181 repression 132 self-object 61–2 resilience xxxii, 65, 187 self-soothing 160, 166, 183 resistance: in analyst and analysand 190–1 sensation(s): in the autistic state 177; as returning loop 54 basis of cognitive and emotional life 12; reverie 20, 63, 78, 93, 109, 187–8 as foundation of the mind xxxii; role Rey, H. 100, 110, 112 in primordial terrors 175; soft and hard Downloaded by [New York University] at 03:54 14 August 2016 Rhode, M. 95, 99 xxxi, xxxii, 26; of threatened fetus 38–9; ‘rhythm of safety’ xxxv, 165, 176, 182 undue significance of, in premature infant rhythmic muscular activities 166 20; utilization of analyst for engendered rhythmicity 157, 158, 166 177, see also auditory sensations; sensory Rimland, B. xxiv experiences; tactile sensations risky behaviour 27 sensation-dominated experience xxxvi, Robert 159–60 157–60, 171 Rochat, P. 72 sensation-dominated psychology xxiii rocking xxvii, 166, 176 sensation-ego: loss in 64–6 rootedness xxxiii sensation-objects 184 Rosenfeld, D. 15, 66, 155 sensation-shapes 184, 185 Rosenfeld, H.A. xxiii, 38, 134 sense of self 63, 73, 131, 165 234 Index

sensory apparatus: projection of 140–1 sibling jealousy 208 sensory channels: integration of two A Significant Element in the Development stimuli involving different 116 of Autism 9–10 sensory cohesion: masturbation ad warding silent patient: learning to understand off a loss of 168 moods and feelings of 141 sensory containment 164–5 Silverman, D.K. 5 sensory experiences 97, 114, 170 simultagnosia 129 sensory floor56 , 166, 170 Sinason, V. 15 sensory integrations xxxii ‘sippy cup and bottle/breast’ routine 24–5, sensory modulation 115 26, 27, 30, 31, 33 sensory-mental-bodily containment 88–9 Siskou, J.D. 62 sensory-psychic split 199 skin: the back, the background, the gaze sensuous objects xxxi, 19, 21, 26 and the 55–8; as a body boundary 100; ‘separability from the object’ 153 boundary of the womb and development separateness 159; analysts of a sense of 19; development of a acknowledgement of pain and dread ‘sensuous’ 12; equated with the skin of 186–7; anxiety connected with of the Face 109; integrity of 107, 167; perception of 46; awareness of, as use of analyst as a second 169, see also an existential issue 186; awareness second skin formation of, in object-related and autistic skin surface: attempts to substitute for states 177, 178; dramatization of 89; a deteriorating sense of cohesiveness echolalic speech and obliteration of 47; 167; sensory contiguity/experience and existential terrors through experience object relations 157, 161; use of autistic of 111; obliterating distinction between objects 182; utilization of analyst for togetherness and 183; working through sensations engendered by 177 and toleration of 187, see also bodily skin-function 66 separateness; impinged separateness skin-to-skin adhesiveness 13 separation: alcohol abuse and overeating as small joints 61, 62 a denial of 113; and anti-social tendency smell 100 93; anxieties 26, 51, 138–9, 147; social competence 72 expressing pain of 121–2; feelings of, social cues 83 invoked by goodbye 33; hospitalization social interaction 73 and trauma of 146; reaction to, in social relatedness 74 object-related and autistic states 177; soft sensations xxxi, xxxii, 26, 158 twinning phantasies and exclusion of softness xxxii, 45, 57, 65, 183 43; working through internal objects solidification 66 and depression 124–6 somatization 131 severe autism 73 sound-object 41, 48–50, 52 sexual maturity 100 Sours, J.A. 207 sexual phantasies 138 Sowa, A. 31 sexuality: fantasies 143; of parents, as space/no space 13, 14, 100 Downloaded by [New York University] at 03:54 14 August 2016 overwhelming 207–8 spared function 70 shadow person 108, 113, 196, 206 speculative thinking 85 shapes: use of, in auto-sensuous phase of Spensley, S. 11, 40 development 173n1, see also autistic sphincter control 47, 61, 86 shapes; felt shapes; normal shapes sphincterless tube-ego 66 shared play 74 Spitz, R. 155 shell-type child see encapsulated child splitting xxxvi, 26, 51, 66, 177; between Shevrin, H. 20 psychic and the material 195–208; fear ‘shock absorber’ function 86 of aggression as a cause of 207; of short-lived ‘awakenings’ 201 sexual feelings from oral ones 140 shoulder 61 Squire, L. 115 Shuttleworth, J. 3 stealing 93 Index 235

Stein, R. 193n9 three-dimensionality xxxi, xxxii, Steiner, J. 197 xxxvi, 53, 66, 129; pivot between Stern, D. 3, 5, 11, 78, 155 two-dimensionality and 55–8; vocal stimulus richness 71 container 48–50 stimulus scramble 19, 21, 35 three-person psychology 70 Striano, T. 72 three-person social capacities 72 Stroh, G. 14 thumb-sucking 67, 183 ‘stuck between two worlds’ 19–36 Tischler, S. xxiii, xxxiii stuck to/sticking to 14, 62, 63, 66, 67, 130 togetherness 89, 183 subjectivity 157, 158, 170, 171 tongue xxxii, 152 sucking 66 touch see tactile sensations suction tentacle 62, 63 Tousseing, P. 20 superego 27, 28, 62, 92, 121, 131 transference 58, 65, 73, 203; analysts’ taking survival xxxviii, 14, 19, 35, 38, 40, 100, in the 129–30, 187, 188, see also counter- 109, 184, 192n3, 202 transference; infantile transference; Süskind, P. 191n3 paternal transference sweets 95 transgenerational factors 112 symbiotic love object 10 transitional objects 26, 27, 192n5 symbiotic phase xxix, 4 transitional space 177 symbol formation xxiii, xxxvi, 171, 176 trauma: of hospitalization 21, 36, 146, symbolic expression 22 149–50; pain of 16; re-evocation/re- symbolic play 58 enactment of 15; sealing off 15, see also symbolic thinking 131 infantile trauma; prenatal trauma symbolization 15, 58, 118, 122, 123–4, Trevarthen, C. 3, 11, 37, 78, 155 138, 177 triadic skills 72 symbolon 130 tripartite object 104–5 symbols: autistic contiguous anxiety and tripartite structure 105–7, 108, 110 the binding power of 170–2 truculence 98, 99 Symington, J. 16 trunk/head junction 61 Tustin, A. xxi tactile hallucinations 181 Tustin, F. 155; adhesive equation 107, 167; tactile sensations 40, 41, 45–6, 47 analysis of autistic states of adults 174–5; talk: incessant 141 analysts’ bravery and resilience 187; on Tavistock Clinic xxi–xxii, 73 annihilation anxiety 118; anorexic patients terror(s): autistic contiguous mode 172; 100, 112; autistic barrier 189; autistic existential 111, 175; of falling infinitely children’s body image 101; autistic 11; liquid states and evocation of 22; defences and the experience of premature psychogenic autism as the narrowing of birth 35–6; autistic objects 192n5; autistic perception through xxix; re-experience shell 197; bodily anxieties 66; body ego of 50; role of sensation in primordial 54, 56, 57, 58; discussion of pathological 175; of slipping into nothingness 188 autism 64–6; encapsulated child xxiv, Downloaded by [New York University] at 03:54 14 August 2016 theory of mind 14, 70, 71 xxv–xxvi, xxx, 27; introduction to life Theory of Thinking xxxii and work of xxi–xxxix; maternal therapists: attachment to 99; imitation by depression 52; miscarriage of motivation 169–70 184; mother’s ‘shock absorber’ function there-ness 181 86; normal autism 173n1; peripheral thinking: abstract 127; concrete 140, vision 185; precipitation anxiety 143; 197; infancy and awareness of 61; in premature awareness of physical object-related and autistic states 177; separateness 152; prenatal trauma and speculative 85; symbolic 131, see also autism 37, 38, 42, 51, 53; re-enactment of Theory of Thinking catastrophic birth experience 101–2, 113; third object 140 sensuous experiences 114, 159; ‘stuck Thomas xxxiv–xxxv between two worlds’ (fetal life and infant 236 Index

life) 20; two types of experience with vocal container (three-dimensional) 48–50 objects 158; vision, hearing and autism 41 vocal register (Rosetta’s) 46–8 twinning phantasies 42–4 voice: contrast between patient’s withdrawn ‘two halves of the body’ 58–60, 67 life and 196; discovery of, and freedom two-dimensionality xxx, xxxix, 40, from adhesive closeness 51, see also 41, 51, 62, 132; pivot between three analysts’ voice; jungle voice; maternal dimensionality and 55–8 voice two-ness xxxii, xxxiii, 175, 177, 186 voice-mind (maternal) 52, 53 two-person psychology 70 vulnerability xxxvi, 180, 181, 189, 190–1, two-person relationships 72 193n10 vulnerable infant 13 unconscious fantasy xxii, xxxii, 177 unconscious phantasy 27, 67, 68, 162, 168 walking disorders 128 United States 3, 5, 83 white psychosis xxxiv unmediated stimulation 21 whole-object relations 95, 165 unmentalized experience 41, 191n2 William 71 Urwin, C. 14 Williams, G. 112, 198 Winnicott, D.W. xxiii, xxix, xxx, xxxi, vampire anxieties 66 xxxii, 9, 10, 11, 13, 14, 62, 93, 107, Vegopoulo, T. 207 134, 147, 155, 169, 177, 185 verbal containment 50 withdrawn children xxiii, xxvi verbal interaction: clustering in 47 Wittenberg, I. 10–11 vermis cerebelli 115 words: experienced as hostile missiles 140; vermis hypoplasia 115 preoccupation/fascination with 139; vertebral axis 58, 61, 67 reaction to mental food of analysts’ 114 verticality 55, 60, 75 working through 187, 189 vision 41, 71–2, 185 wrist joint 61 visual capacity xxiv visual regard 72 Young, T.M. 114 Downloaded by [New York University] at 03:54 14 August 2016