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DOI: 10.1177/0003065114539839
2014 62: 475 originally published online 9 June 2014 J Am Psychoanal Assoc
Elizabeth J. Levey
Development
Effective Treatment Strategies for Autism During the First Five Years of

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j
a
P
a
475
DOI: 10.1177/0003065114539839
62/3 Elizabeth J. Levey
EFFECTIVE TREATMENT STRATEGIES
FOR AUTISM DURING THE FIRST FIVE
YEARS OF DEVELOPMENT
T
here is a gap between, on the one hand, psychoanalytic theory
regarding treatment for autism that recognizes both relational and
body-based treatment and, on the other, conventional psychoanalytic
treatment. Recent psychoanalytically based empirical research data indi-
cate that treatment strategies exist to address the ineffective and patho-
logical coping strategies present in infants and children with autism
spectrum disorders (ASDs). This panel, chaired by Stephen Seligman,
used videotape clips of therapy sessions over the course of a multi-year
treatment of a child beginning at ten months, as well as verbal presenta-
tion of case material by the treating psychoanalyst, Molly Romer Witten.
Gilbert Foley, a psychoanalyst, and Gerard Costa, a developmental psy-
chologist and infant mental health specialist, were discussants; together
they laid out the principles of the change process and illustrated the
complex issues present early in life for children who present with behav-
ior on the autism spectrum.
Seligman began by introducing the topic of the psychoanalytic theory
of autism by reviewing past and current controversies. The problem with
the refrigerator mother theory, which postulated that autism is an infants
defensive response to a cold, rejecting mother, was that it defined the prob-
lem unidimensionally. The pendulum has since swung in the other direc-
tion, and a new unimensional error is currently favored: the attribution of
primary causal influence to neurobiological deficits in the infant. The
truth, Seligman said, involves the interaction of endowment and environ-
ment. This transactional perspective is well described in the work of
Panel held at the Winter Meeting of the American Psychoanalytic Association,
New York, January 18, 2014. Panelists: Stephen Seligman (chair), Molly Romer
Witten, Gilbert Foley, Gerard Costa.
539839APAXXX10.1177/0003065114539839Panel ReportEffective Treatment Strategies for Autism
research-article2014
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P a n e l R e p o r t
476
George Engel, a leading proponent of the biopsychosocial theory of
health and illness. Engel published a paper on the theory in 1977, and
today, thirty-seven years later, it is widely accepted as an explanatory
model for such medical conditions as asthma and migraines, as well as
psychiatric conditions like depression and anxiety. However, the unfortu-
nate legacy of the refrigerator mother theory has left many clinicians and
researchers reluctant to view autism through this lens.
Witten opened her talk with a quote from Frieda Fromm-Reichmann
(1990): Severe loneliness cannot ordinarily be endured more than tem-
porarily without leading to psychotic development. This aptly summa-
rizes Wittens theory of the development of autistic features in a
ten-month-old boy brought to her for consultation.
Witten reviewed for the group the threefold criterion suggested by
Stanley Greenspan (2000) for the diagnosis of autism: the child must
demonstrate simultaneous dysfunction in sensorimotor integration, com-
munication, and interpersonal relating. While many autism researchers
lump these characteristics together, psychoanalytic treatment offers the
possibility of psychological integration and supports growth of an inde-
pendent self (Tsakiris 2000). It does this, Witten suggested, by acknowl-
edging the discrete and multiple meanings of behavior, rather than simply
tracking observable behavior.
Witten described the presence of all three domains of dysfunction in
her patient. She theorized that the presence of low motor tone at birth
limited his ability both to meet his physical needs and to communicate
them to his parents. This in turn created a sense of isolation from his own
body and from the physical world. Based on their own complex histories,
the parents misinterpreted his cues. Wittens theory of the case was as fol-
lows: (1) The insufficient motor tone observed from birth to seven months
created within the baby a psychological isolation from his own bodily
experience and hence delayed the development of affects and affective
range. (2) This low motor tone and inadequate affective range allowed the
organization of only muted facial expressions, such that the parents did
not know that the babys sensory barrier was repeatedly breached; during
these unaddressed breaches, he experienced dissociation. This recurrent
dissociation, brought on by an unmet need for soothing, constituted expe-
riences of loneliness. Perhaps most important, this recurring dissociation
prevented the development and expansion of the capacity to engage
bodily aggression, first in the service of basic physiological functions that
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EFFECTIVE TREATMENT STRATEGIES FOR AUTISM
477
guide developmental momentum, and then in providing the motivation
for relating, as well as a capacity for communication. (3) The meaning the
parents ascribed to their babys dissociative behavior prevented them
from comprehending the meaning of his cues and hence his needs. The
babys loneliness, combined with isolation from his own ongoing experi-
ence of muted or distorted affect, unmodulated by parental containment,
led to autistic behaviors such as gaze aversion, a desire not to be touched,
and aimlessness. An aimless searching in the environment precluded the
organization of aggression in the service of learning to reach out, explore,
and relate to others.
Baby B, as Witten calls her patient, was ten months old when
brought to her office for consultation. From birth, he had had difficulty
latching on to feed, and at four months had met the criteria for failure to
thrive. This led to referrals to a number of specialists, all of whom gave
the family the general message that B was developing normally and that
his low weight was due to his mothers anxiety about feeding. At seven
months they consulted a doula, who recommended trying a preemie
nipple, which proved helpful. The parents already believed that their child
had autism, based on input from family and friends with autistic children,
and through these contacts they were referred to Witten. Immediately
apparent were Bs difficulty feeding and his tendency to disengage and
move about aimlessly; the mothers anxiety and sense of rejection around
feeding; and the fathers reluctance to engage spontaneously.
In working with the family, Witten saw the mother once a week alone,
mother and baby together twice a week, and all three together for a double
session once a week. She also met periodically with the father alone. In
addition to seeing Witten, B worked with a team that included a speech
therapist, occupational therapists, and play therapists.
Over the course of their work together, Witten learned about the
meaning that being a parent held for Bs mother (M) and father (D). M
was the oldest child born to a depressed mother and a father who was
absorbed with his work. When she was five years old, her mother could
not get out of bed, and M took on the role of mother to her younger sib-
lings, a job at which, being a child herself, she was not fully competent.
She held a firm belief that she was not a competent mother to her own
child in a way that echoed that early experience. Bs feeding difficulties
reinforced that belief. His falling asleep when M tried to feed him also
evoked the way her own mother had taken to her bed, and she interpreted
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his falling asleep as a rejection of her and a confirmation of her
incompetence.
The father, D, was the youngest child in his family, separated by
more than ten years from the rest of his siblings. By the time he turned
ten, and his parents divorced, he had been the only child at home for a few
years. His parents had not discussed with him their plan to divorce. One
day he simply came home from school and was told by his mother that his
father no longer lived with them and that the family now consisted of just
the two of them. As he was the last child, he lived through his mothers
post-divorce depression, which lasted until he went to college. For many
years, D wondered why his father had abandoned him and felt unlovable
in a basic way. As an adult, he and his father started a company together,
but their work relationship always seemed contentious. Ds father had
died unexpectedly a year before D and M met. Together, D and Witten
discovered a number of meanings this history may have infused into his
relationship with his son. As Andr Green (1999) has said, We carry
within ourselves the totality of our past, which does not mean that we
carry it as memories but as a set of organizers (p. 69). In response to his
feelings of rejection by his own father, D had become so defended against
his desire for a playful father-son relationship that he simply could not
access his capacity for play.
During her talk, Witten showed four video clips meant to illustrate
her experience in the room with this family and Bs development over the
course of therapy. With the first clip, Witten showed how the family
handled feeding. When B seemed hungry, M pulled out a bottle, at the
sight of which the baby crawled across the floor to the couch where she
was sitting. She carefully placed the bottle into his mouth, pointing it
downward, allowing gravity to do much of the work. Ms experience had
been that B seemed to stiffen when he was held, so she allowed him to
feed in this way, not wanting to force him to be held to meet her own need
for closeness. She was clearly disappointed with this arrangement,
though, and commented that it seemed to be further evidence that she was
not a good enough mother.
It was clear to Witten that M was attaching meaning to Bs behavior
that was rooted in the past and was not an accurate interpretation of Bs
experience in the present. The parents were most bothered by Bs lack of
eye contact and apparent aversion to being held. They believed this was
motivating his preference to feed from the floor on all fours. When B
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EFFECTIVE TREATMENT STRATEGIES FOR AUTISM
479
stiffened when held, his mother, seeing this as confirmation of her
assumption, retreated from pursuing further engagement, which her son
seemed not to want; thus she avoided feelings of remembered rejection
that were acutely painful to her.
Witten had another theory. Given this difficulty feeding from birth,
and taking the usefulness of the preemie nipple as a helpful clue, she
believed that Bs low motor tone was a primary factor driving these
downstream problems. She encouraged the mother to hold B and showed
her how to wrap her arms around him in a way that was motorically con-
taining and positioned them face to face. M became comfortable with
this, and within a few sessions B began to explore her face with his eyes
and hands.
In the next clip, also from the second session, B had stuffed a two-
inch piece of banana into his small mouth such that he could not breathe
or swallow, or move the food around with his tongue. B moved aimlessly
around the office, not seeking out his parents for help, and their worry
was evident. Witten coached D to move slowly toward B and urge him to
come sit on his lap and stop moving so he could organize his motor activ-
ity around eating the banana, which he could neither chew and swallow
nor figure out how to spit out. Eventually, in his fathers lap, he was able
to chew and swallow the banana.
In the third clip, from the sixth session, as M and B were developing
a comfortable feeding pattern, the low rumble of a truck driving by the
office interrupted their connection. Bs attention shifted from eating to
searching for the source of the frightening sound, and his hand moved
away from his mothers face. Ms smile faded as her face dropped, con-
veying her experience of rejection and isolation. B resumed sucking but
with his gaze averted and without apparent interest in playing with M.
Witten coached the mother to pull back gently on the bottle in order to
capture Bs attention. She did so for a brief moment, and as the bottle was
returned to him, B looked up at his mother and reconnected with her.
Witten described Bs disengagement following the noise from the
truck as a dissociative state of goal-less drive reduction. There was a
discussion involving the audience about whether this episode was truly
dissociation or was simply distraction. The question was raised as to the
precise meaning of dissociation. Witten explained that she observed B
stiffen and avert his gaze while continuing to suck, which she character-
ized as dissociation from the perspective of drive theory. B did not orient
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toward the noise but did shift attention away from his mother. He contin-
ued to feed but in a way that was relationally disengaged, as though he
had shut down his affective contact with the external world in an attempt
to mute the overwhelming auditory input he had just received.
The final video clip showed B at thirty-three months engaged in pre-
tend play with his parents. The session followed a meeting between
Witten and D in which the father shared that B feels lonely when D is
at work during the day. D had experienced Bs statement to that effect as
manipulative. In the session with Witten, he was able to work through a
series of associations to connect it to his own painful experience of losing
his father when his parents divorced. Poignantly, he asked Witten, Do
you think its okay if I tell him I miss him too?
In the clip, B has brought his favorite toy truck, an excavator, into
the session. He is playing the Officer, whose job it is to drive the exca-
vator. M is Dexter, a worker who goes off to build buildings. D plays
the Fireman, who rescues people. Dexter and the Fireman both want
turns to drive the excavator. The Officer initially refuses them, but when
they show disappointment, he relents. B then associates to the anger he
felt at giving up control of the excavator, telling his father that he was
mad at him for going to work that day. Then B tells D that he missed him.
At this point the three of them begin to talk together about loneliness.
This seems to overwhelm B, and he starts to clean up, as if the session
were over. The conversation eventually turns back to loneliness. D tells B
that he missed him too. B then collapses on the floor, flat on his back,
losing all motor tone, in an illustration of infantile defenses described by
Fraiberg (1982). Eventually returning to the play, B introduces an object
called the cheese. Dexter and the Fireman have made the Officer angry
by driving his excavator, so they are banished to the cheese, where loneli-
ness serves as their punishment. In Bs articulation of loneliness as pun-
ishment, Witten was reminded of Bs disengagement as an infant when M
did not respond to his cues or meet his needs. In the play, Dexter and
Fireman had not responded to the Officers cues that he did not want to
share the excavator and had persisted in their pleading. At home that
night, after the session, B curled up with M for his bedtime bottle. M
texted Witten that night: Boy, it felt like this is what I have been waiting
for since he was born.
In his discussion of Wittens presentation, Foley spoke about the
complex etiology of autism, with genetic vulnerabilities and caregiver
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EFFECTIVE TREATMENT STRATEGIES FOR AUTISM
481
factors interacting in continuous fashion to shape the childs develop-
mental trajectory. Using the term psychogenic autism, he made a dis-
tinction with respect to the degree of genetically based social impairment
present in a particular case. He was careful to note that even in the pres-
ence of significant genetic loading for autism, the infant-caregiver dyad
still plays a crucial role in the childs social development, precisely
because of the potential for it to be derailed by the childs lack of social
reinforcement by caregivers. In his work, Foley has found feeding to be
particularly difficult for infants with sensorimotor impairment. He has
observed that severely altered patterns of action and reaction, sucking
and swallowing, muscle tone, and so forth in the baby can set in motion
a cycle of severely compromised patterns of interaction contributing to
arrested attachment in parents who are essentially competent and loving
caregivers (Foley 1985).
Foley considered Baby Bs to be a case of psychogenic autism for
two reasons. First, his primary impairment appeared to be in the sensori-
motor domain. The developmental trajectory he began to follow once in
treatment shows that neurobiologically he was capable of social relating.
Second, the meaning to his parents of Bs failure to relate held clear and
intense echoes of the past for both of them. B lacked the sensorimotor
capacity to entice his parents. They interpreted the problem to be their
deficit in enticing him, and they retreated, feeling rejected. As the case
unfolded, it was evident that B and his parents shared an unconscious
experience of the connection between loneliness and anger. Loneliness
can be used to punish another for making one angry, and self-imposed
loneliness (retreat) can be used to protect others from ones angry feelings
and aggressive impulses. Thus, Bs own annihilation anxiety had strong
resonance for his parents. Foley further suggested that repair and contain-
ment are essential to the analytic work in this case. In the room with three
individuals who had no internal framework to allow them to work with
their aggression, Witten contained it for them until it began to be safe to
explore it relationally with one another.
Foley again raised the question of dissociation and whether the term
can be applied in this case, as Witten did when the truck drove past her
office and B disengaged from his mother. He argued that given Bs appar-
ent hypersensitivity to external stimuli, his shutting down and turning
away could be best understood as a freezing response, akin to fight,
flight, or feign death. Foley went on to say, though, that an infant
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P a n e l R e p o r t
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repeatedly forced to over-rely on shutting down as a coping mechanism
may well be at higher risk for developing defensive patterns of with-
drawal and dissociation (Foley 2006).
Costa provided an overview of what is known about the neurobiol-
ogy of autism. An understanding of the neurobiological processes at work
strongly argues for thinking about and caring for patients from a multi-
sensory, multidisciplinary perspective. A few of the key findings he dis-
cussed relate to hemispheric localization and the role of the limbic system.
Right hemisphere structures appear active earlier than left hemisphere
structures. The former are the parts of the brain that recognize affect and
tone rather than the content of what is said. Shared affective and neuro-
logical states (we circuits) are intrinsic to the infants psychological
development in a relational context (Siegel 2010).
Limbic development begins early and occurs in a relational context
(Schore 2011). The limbic system plays an essential role in emotion pro-
cessing and memory, implying a link between emotional memories and
the processing of current emotion. The limbic system is also involved in
shaping neural circuitry. When a baby senses safety, warmth, and secu-
rity, Costa explained, the limbic system gets wired to attend, remain
calm and engaged, and to store memories about the body, about the world
and the people who are there for them. However, if the infant is exposed
to a stressful environment, the limbic system is activated in a way that has
negative effects on development. High levels of early stress perceived by
the amygdala activate the hypothalamic-pituitary axis, releasing cortico-
steroids and impairing prefrontal cortical development. All this is to say
that early intervention in children with ASD vulnerabilities is all the more
compelling when considering the effects of early caregiver interactions
not only on the mind but also on the brain.
Costa referenced a recent study, by a group of researchers at
Vanderbilt, which found that children with ASDs process visual and audi-
tory input separately and have difficulty processing simultaneous input
into different sensory modalities (Stevenson et al. 2014). If B has this
ASD feature, it might have contributed to his difficulty maintaining eye
contact with his mother when he heard the noise of the truck. Costa
observed that Baby B came to the relational process with constitutional
neurobiological compromises and that both parents arrived with histori-
cal, intrapsychic, emotional, and behavioral dynamics that compromised
their capacity for attuned, responsive, and co-regulated care of their child.
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In children with such constitutional vulnerabilities, both the babys sig-
nals and the caregivers responses are not well matched and synchro-
nized, and an alteration occurs in the unfolding developmental trajectory
of child and caregivers. This is compounded by parental projections and
interpretations of the babys miscues.
A rich discussion followed the panelists presentations, with a num-
ber of thought-provoking questions from the audience. People wondered
whether B truly had an ASD. Without Wittens work with this family, it is
impossible to say whether B would have followed an autistic develop-
mental path.
Seligman raised the question whether there is a distinction between
biological and psychological autism, as Foley had suggested. There was
general agreement that every case is impacted by both biological and psy-
chological factors, to varying degrees. Costa offered that the diagnosis
describes a cluster of symptoms that is not biologically meaningful, and as
we learn more about the brain, it is becoming obsolete. Witten suggested
that autism is a process rather than a state of diseased functioning.
Wittens thoughtful, nuanced case presentation raised questions that
are essential to our understanding of autism and hold significant treat-
ment implications. Like all psychiatric diagnoses, autism is defined by
the presence of certain symptoms and not by a specific pathophysiologi-
cal process. It is a final common (though quite heterogeneous) pathway
for what is likely a wide variety of primary etiologies. The fact that a child
who has displayed autistic behavior at ten months can fall in the normal
developmental range at age four highlights the importance of taking the
time to get to know a child and a family well in order to develop an under-
standing of all the factors at play, to intervene in multiple domains, and to
help the family make meaning of its experience.
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32 Fruit Street
Boston, MA 02114
E-mail: ejlevey@gmail.com
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