(Maresfield Library) Frances Tustin - Autism & Childhood Psychosis-Karnac Books (1995)

AUTISM
AND
CHILDHOOD PSYCHOSIS
Frances Tustin
AUTISM
AND
CHILDHOOD PSYCHOSIS
Frances Tustin
Foreword by
Victoria Hamilton
London
K A R N A C BOOKS
First published by
The Hogartll Press Ltd, 1972
This edition reprinted in 1995

with their permission by
H. Karnac (Books) Ltd.
Karnac Books Ltd.
118Gloucester
58 Rod
Finchley Road
London SW75HT
London NW3 4QY
Copyright 63 1972 by Frculces Tustin

Foreword copyright O 1995 by Victoria Hamilton
All rights resewed. No part of this publication may be reproduced.

stored in a retrieval system, or transmitted in any form or by any
means, electronic, mecha~ical,photocopying, recording, or otlier-
wise, without the prior permission of the publisher.
The rights of Frances Tustin to be identified as author of this work

have been asserted in accordance with 99 77 and 78 of the Copyright
Design and Patents Act 1988.
Brltlsh Llbrary Cataloguing in Pubilcatlon Data

A catalogue record for this book is available from the British Library.
ISBN: 978 1 85575 110
1-85575-1 10-01
Printed in Oreat Britain by BPC Whcatons Ltd. Exeter

To the parents who have
entrusted their children to my care
ACKNOWLEDGEMENTS
The responsibility for the views and insights described in

this book is my own, but there are many people to whom I
am indebted for inspiration and help.
The deepest influence on my thinking has naturally been
that of Dr. W. R. Bion with whom I had the privilege of
many years of personal analysis followed by a short but
helpful assimilative period with Dr. S. Leigh. I have also
learned much from my husband, Professor Arnold Tustin,
who from his background as a physical scientist. has
made astringent comments on every chapter of this book.
Supervisors, colleagues, friends, patients and their families
have been a further source of stimulation and learning.
Particular gratitude is felt towards the psycho-analysts who
compose the Melanie Klein Trust who not only gave their
time to reading this book, but generously encouraged and
expedited its publication.
Finally, I want to thank Dr. Mary Lindsay who made it
possible for me to have the necessary time for revision of
the manuscript for publication.
vii
CONTENTS
ACKNOWLEDGEMENTS vii
UST OF lLLUSTRATIONS AND CHARTS X
FOREWORD by Victoria Hamilton xi
One Autism
Two Psychotic Depression
Three Autistic Processes in Action
Four 'Grit' and 'Second Skin' Phenomena
Five Autistic Processes: Further Discussion

Six Autistic Objects
Seven Systems of Pathological Autism

Eighl Classification as a Basis for Treatment
Nine Early Infantile Autism and Childhood
Schizophrenia as Specific Syndromes
Ten A Clinical Description of Childhood
Schizophrenia
Eleven A Setting for Psychotherapy
Twelve Phases in Psychotherapy
Conclusion
REFERENCES
INDEX
LIST OF
ILLUSTRATIONS AND CHARTS
Illustrafions
1: John's Picture at the End of Treatment
2: David's Monster
3(a) and (b): David's Amour
Charts
I: Types of Autism: Precipitating Factors
11: Types of Autism: Differential Features
III: Differential Features of Early Infantile
Autism and Childhood Schizophrenia
FOREWORD
Victoria Hamilton
Autism and Childhood Psychosis was first published in

1972 by Hogarth, London, and a year later by Jason
Aronson, New York. Subsequently, it was translated and
published in France, Italy, Brazil, and Argentina, where it is
now in its third edition. In France, it is a 'livre de poche'.
Twenty years ago, the book was greeted by a group of
Italian therapists working at a unit for psychotic children at
the Institute of Childhood Neuropsychiatry, Rome Univer-
sity, as 'a ship coming into harbour bearing precious cargo'
(Tustin, c. 1985). Here was a theoretical model that pro-
vided an anchor for therapists bewildered by the array of
bizarre behaviours that seemed to defy scientific explana-
tion and human intervention.
Autism and Childhood Psychosis is Frances Tustin's first
book and the original statement of her views on autistic
states of mind and the genesis of varieties of childhood
psychosis. In it, she tackles problems of diagnosis as these
relate to therapeutic intervention. Looking back at this early
work from the vantage-point of 20 years and three more
publications, it is fascinating to read the promotional state-
ment on the original book jacket, which aptly portrays the
approach that has become the hallmark of Tustin's writing:
..
'In a remarkable book Frances Tustin . reveals a mixture
of common sense and compassionate insight which, with
her clearly presented clinical material and sensitive in-
terpretations, allows the reader to enter the strange world of
.
psychotic children. . . Mrs. Tustin's book is psychoana-
lytic but not sectarian. It has the great virtue of springing
directly from her own experience, and it will thus be a
source book for therapists from every school of depth
psychology. '
xi
AUTISM AND CHILDHOOD PSYCHOSIS
Before becoming a child psychotherapist, Frances Tustin
was a school-teacher, specializing in teaching English and
Biology. Her books are the product of someone who can
express her experiences in an imaginative and scientific
manner. In addition to Local Authority employment, Tustin
worked in a number of progressive schools, where teaching
methods were as much the subject of investigation as the
subjects taught. These educators were examining the con-
text, or optimal conditions, for learning-how children
learn to learn. Many child analysts, notably Anna Freud
and Marion Milner, have been teachers. They bring to their
therapeutic work specialized communicational and disci-
plinary skills. In education and therapy, learning and un-
derstanding go hand in hand. All of Tustin's writings tell us
directly how she couches her interpretations; we get a very
clear idea of the simplicity and precision of her choice of
words, as well as her emphasis on the regularity of the
treatment setting. Orderliness provides both child and
therapist with a safety-net, or, as one recovering child
called it, 'a cradle', so that over time both c'an endure the
tenors of falling into the 'black hole', the well of nothing-
ness, that dominates autistic states of mind. The therapist's
main task is to resist being 'nothinged' and to stand up for
what Colywn Trevarthen, the contemporary infant re-
searcher, has called 'live company'. As Tustin notes, these
children have 'very little psychic life other than that of
sensation'. The 'feeble flame o f . . . psychic life has to be
fanned by every means at our disposal' (p. 153, this vol-
ume).
I am grateful to Cesare Sacerdoti for asking me to write
this foreword, and I take the opportunity to trace the devel-
opment of one analyst's use of theory and practice over a
50-year span. Aurisni and Childhood Psychosis contains all
the ideas that culminate in Tustin's last public statements.
We meet the characters 'John', 'David', and 'Peter' who
have become 'classic' cases for readers of Tustin's work.
FOREWORD
Psychoanalysts, like Tustin, with an artistic and scientific
bent have an advantage in that they can present their work
in both ordinary and specialized language. Thus, in this
early work, Tustin describes her experiences in many of the
same words as in her writings of the 1990s-the 'black hole
of bodily separateness', the 'heartbreak at the centre of
existence', the 'protective shell against an original agony'.
etc. But, it is in her use of theory that we are privileged to
observe a fundamental shift of perspective. And, of course,
re-descriptions of experience under different concepts or
theories necessarily affect our experience and clinical prac-
tice. As with the body of Freud's work, the faithful chron-
icler of Tustin's books enters into a puzzle that the author is
trying to solve. Parts of theories are pulled in, concepts
disappear and are replaced by new pieces, until the author
is satisfied enough with the overall 'gestalt' to discard early
formulations publicly as 'the perpetuation of an error'
(Tustin, 1994a).
Normal Primary Autism

This brings me to the central thesis of this book, which was
later regarded by Tustin as a fundamental error: the theory
of 'normal primary autism'. I devote much of the foreword
to a discussion of what happened to this theory. Unfortu-
nately, I am unable to elucidate the second subject of this
book-Tustin's concept of 'regressed secondary autism'
and the 'dispersal' techniques that eventuate in childhood
schizophrenia. Tustin makes a clear distinction between the
two conditions and their implications for diagnosis and
treatment. In a recent statement, however, Tustin affirms
that, in line with current formulations. she would have re-
titled this book 'the autism of childhood psychosis'. This
caption brings the two diagnoses close together and reflects
Tustin's later belief that autistic processes organize the
lives not only of autistic and psychotic children, but also
xiii
(to a much lesser degree) of neurotic adults as well as of
ordinary, well-functioning people.
In the 1950s and 1960s. when Tustin was formulating
her theories, psychodynamic approaches to autism were
embryonic and scattered. Autistic children were considered
mentally defective and ineducable and were consigned
to institutions. In his seminal 1943 paper, Leo Kanner
proposed that 'a basic affective disorder' underlay and
prompted the cognitive impairment of autistic children. He
introduced the idea that emotional factors contributed to
what was then considered an organic illness. According to
Kanner, autistic children suffered from a 'disability to re-
late themselves in the ordinary way to people and situations
from the beginning of life' (Kanner, 1943). Tustin shared
Kanner's belief, never veering from this view, although she
struggled to fmd a satisfactory account of the aetiology of
this condition. Questions of aetiology are inextricably en-
twined with theories of normal development. As Tustin's
developmental metaphor shifted, so did her views on
the 'psycho-genesis' or-to use her final formulation-
'psycho-biology' (Tustin, 1994a) of autism.
Frances Tustin referred many times to the generative
year-from 1955 to 1956-she spent at the James Jackson
Putnam Children's Center in Boston. John Bowlby had in-
troduced her to the work of the centre, which focused on
the research and treatment of 'atypical' children, many of
whom were autistic. Not only did Tustin work at the centre
as a therapist, she also looked after some of the children in
their homes, thereby enabling their parents to have a rest. In
addition, she read all of the centre's records-covering a
ten-year period--on these children. Tustin tells us that she
was 'very moved by the tragedy of the autistic condition
for both parents and children' (Tustin, c. 1985). She con-
stantly emphasized the care, dedication, and thoughtfulness
of the mothers of autistic children; she disagreed strongly
with those who have portrayed them as cold 'refrigerator'
FOREWORD
mothers. Very often, these mothers are unusually sensitive
and caring people, but they lack confidence and the re-
silience that comes from external and internal support.
Little wonder that the mother's own infantile insecurities
are compounded by her baby's non-responsiveness, so
that 'the "black hole" seems to be bandied between mother
and infant through the bodily channels of empathic
communication' (p. 26, this volume). Tustin forewarns the
over-zealous therapist that autistic children, being 'heart-
broken', 'threaten to break their therapists' hearts' (Tustin,
1990, p. 155).
During her stay in the United States. Tustin was intro-
duced to the work of the American analysts Edward
Bibring, Bruno Bettelheim, and Margaret Mahler. Bettel-
heim and Mahler pioneered the treatment and psycho-
dynamic understanding of autism. As is well known, until
the very end of her life, when she renounced her theory of
normal primary autism and symbiosis, Mahler's theories
formed a consistent extension of Freud's concept of pri-
mary narcissism. E. James Anthony, another early pioneer
in the treatment of autistic children, introduced the term
'normal neo-natal solipsism' (Anthony, 1958) to describe
this stage of early infant development. Essentially, the pre-
narcissistic or 'autistic' infant starts life out of touch with
reality, inhabiting a sensationdominated world, unrespon-
sive to other people except insofar as they fulfil certain
bodily functions. Chief amongst these essential functions is
feeding.
Most traditional theorizing on early infancy relies
heavily on the oral metaphor. Normal primary autism is a
variant of Freud's stage of normal, autoerotic, oral devel-
opment. Relating consists of mouth-tongue-nipple-breast-
milk or no-milk configurations of sensation, in which the
neonate experiences blissfully flowing or excruciatingly
tense, bodily states. These agonizing states of privation are
captured in the words of some of Tustin's patients: 'a prick
in my mouth', 'a nasty black hole in my mouth'. 'spots of
nothing', or 'mouths of pecking birds'. The tension of pent-
up frustration is experienced in a bodily way as grit, gravel,
prickle, bits of broken glass. As a Kleinian, trained to ob-
serve the over-riding importance of the infant's part-object
relationship to the mother's breast, Tustin's immersion in
the autistics' world of inert bits and pieces of people and
animated things fitted in with classical Freudian and
Kleinian theory. The normal autistic infant was barely hu-
man. He or she becomes a person, a whole self. as the split-
up parts are joined; this developmental process is aptly
described by Tustin's recovering autistic patient. John. Fol-
lowing a fall when he bumped his head, John remarked:
'I've got a good head on my shoulders. Can't fall off.
Grows on my shoulders' (pp. 16-17, this volume). These
words indicated John's growing sense of bodily integration.
Autism and Contemporary Infancy Tlteory

Later. Tustin placed her observations within the contemp-
orary perspective of the interpersonal world of the infant.
Viewed from this framework, autistic processes seem far
from normal, signifying instead aberrant developmental
pathways. Since the early 1 980s. the interpersonal view has
become popular amongst psychoanalysts through the works
of contemporary researchers such as Daniel Stem, Lou
Sander, Robert Emde. Colwyn Trevarthen, and others.
Twenty-five years ago, when Tustin wrote this book, the
interpersonal theory was there to be found in the works of
Michael Balint, Ronald Fairbairn, Ronald Laing, Harry
Stack Sullivan, and, closer to home. in John Bowlby's early
formulations of attachment theory. But these views were
not taught in courses during Tavistock Child Psychotherapy
training. Nevertheless, it is fascinating to note that, despite
her use of non-relational theory, some of Tustin's most
FOREWORD
distinctive phrases retain their place in early and late theo-
ries. In her first efforts to portray primary autism, Tustin
uses terms that are now part of common analytic currency.
For example, when referring to Winnicott's term 'omnipo-
tent illusionment' and Bion's concept of 'maternal reverie',
Tustin states that this 'empathic reciprocity [between
mother and infant] fosters the illusion of bodily continuity'
(p. 26, this volume; italics added). Tustin quotes Winni-
cott's statement that the 'notion of interchange is based on
illusion' (Winnicott, 1958, p. 13). Here, we can discern a
mixture of old and new developmental thinking. Another
example: Tustin links the study of primary autism with the
study of an 'embryonic' self. 'Linking' experiences are
provided by satisfying nipple-mouth sensations and by be-
ing encircled in the mother's arms and 'ambience of caring
attention'. These linkings become integrated and contribute
to the integration of 'an emergent self' (cf. Stem, 1985).
Tustin states categorically that 'if this sense of primal link-
ing is lacking, processes exclusively centred on the child's
own body compensate for the lack' (p. 55, this volume).
Just as with Freud's theories of primary and secondary
narcissism, Tustin's first theory of primary autism merges
into her second theory of secondary autism-'encapsulated
secondary autism'. When viewed from a relational perspec-
tive, both primary narcissism and primary autism signify
pathogenic and traumatic ruptures of the normal mother-
infant bond. The difference between contemporary and
more 'classical' Freudian and Kleinian theory is that we no
longer refer to bonding or linking experiences as 'illusory',
as manifestations of omnipotent phantasies, but talk as if
they are a fact of life! Tustin's 'stream of sensations'
forms part of an interpersonal exchange in contrast to auto-
erotically focused body sensations located in the mouth or
belly.
xvii
The Protective Function of Autistic Processes
A central theme of Tustin's work concerns the protective
function of autistic processes. Tustin introduces this notion
in her f m t book, when she tells us that the primary pro-
cesses of normal autism also have a protective function.
They protect the infant from too harsh an impingement of
reality. This early formulation echoes Freud's concept of
the 'stimulus barrier'-a necessary adaptive defence
against the overstimulation incurred by both instinctual
urges and external reality, for which the pleasure-oriented,
sensation-dominated, narcissistic infant is ill-prepared.
Throughout her work, Tustin continues to emphasize the
protective function of autistic processes-her fourth and
last book is entitled The Protective Shell in Children and
Adults-but she changes the context in which normal pro-
tective strategies expand into full-blown autism. The
protective shell of autism is a hard, over-developed, rigidly
maintained, last-ditch reaction against the trauma of a pre-
mature and sudden experience of bodily separateness. In
normal circumstances, however, reality does not impinge in
this harsh way, since, according to contemporary theory.
the infant is pre-programmed to seek out relationships and
to attach hinuelf to specific people, notably his mother.
The 'encasing and enclosing' processes that are captured in
the annour and monster drawings (Figures 2, 3a, & 3b: pp.
38-39, this volume) of Tustin's 11-year-old patient, David,
are directed towards survival in the face of the shock of
premature separateness. The autistic child capitalizes on
normal infant protective behaviours, such as shutting the
eyes, averting the gaze, slumping into sleep, or going rigid,
which are evoked under specific conditions-such as in the
presence of bright lights. sudden noises, looming objects or
the immobile, inwardly directed, face of a depressed or
preoccupied mother.
xviii
FOREWORD
Autism and Trauma
Whereas, in this first volume, these descriptions are placed
in the context of normal non-relatedness, in her final works
Tustin linked the protective shell with trauma. It is part of
the definition of the concept of trauma that we are not
talking about either ordinary life events or average devel-
opment. Following Bowlby's studies of childhood moum-
ing and Mahler's observations of severe grief reactions in
psychotic children, Tustin was to link the emergence of
autistic processes with mouming reactions that typically
follow traumatic events. Tustin focuses on the shock of
bodily separateness and the state of 'numbing' (Bowlby,
1980) that ensues in the face of unbearable physical terror.
Mahler had commented on 'the period of grief and moum-
ing which . . . precedes and ushers in the complete psy-
chotic break with reality . . .' (Mahler, 1961). In successful
treatment, this sequence is reversed. As the autistic child is
un-numbed, he is easily startled; as he unfreezes, severe
grief reactions explode. These are a mixture of 'panic tan-
trums' and unending despair as loss is experienced anew.
In Autisnl and Childhood Psychosis, Tustin does not use
either trauma theory-not readily available at that time be-
cause most psychoanalysts, following Freud, had discarded
trauma as a causal agent-or Bowlby's attachment model
of loss and mouming. Instead, she refers to the concept of
'primal depression' of Edward Bibring (1953). whose writ-
ings she had encountered when at the Putnam Centre, and
Winnicott's concept of 'psychotic depression'. Bibring
traced the state of 'primal depression' to the infant's
'shocklike experience of the feeling of helplessness'.
Tustin tells us that it was only when she presented her
paper. ' A Significant Element in the Development of
Autism' (1966) at a meeting of the Association of Child
Psychotherapists that she was introduced to Winnicott's
work on this primitive type of depression. (Members of this
Association are drawn from a number of London child
psychotherapy trainings-Anna Freudian, 'independent',
Jungian, and Kleinian). According to Tustin, Esther Bick,
who directed the Tavistock child training, 'put us off read-
ing Winnicott, for, as far as she was concerned, he was
misguided' (personal communication in 1993). It is inter-
esting to note that in the paper 'The Mentally I11 in Your
Case Load', in which Winnicott (1963) introduces the term
'primal depression', he quotes John Rickman's social defi-
nition of mental illness: 'mental illness consists in not being
able to find anyone who can stand you.' Rickman, a social
psychologist, army psychiatrist, and conscientious objector,
situated madness in a ~interpersonal
i framework.
Tustin's shift to mi interpersonal perspective led her to
embrace contemporary trauma theory more fully. Indeed.
in a recent statement, Tustin discusses 'murderousness as a
consequence of trauma and non-attachment' (1 994b, p. 2).
Following research into more than 200 cases of serial kill-
ers, Tustin comlnents that the personality of the typical
mass-murderer can be traced back to childhood trauma.
Both serial killers and autistic children have trouble in man-
aging violent feelings. Unlike autistic children, murderers
'have not had the prison of autism to hold their murderous-
ness in check' (Tustin, 1994b, p. 5). Tustin comments that
as the controls of autism break down, violence, in the form
of panic tantrums, breaks out and must be contained by a
firm, sensible, and unsentimental therapist. Eventually,
through the 'infantile transference*, the child begins to
form attachments, and these, together with developing
social ties, 'provide constraints on violence and give pro-
tection' (1994b. p. 5).
In a brilliant passage in this first book, Tustin links autis-
tic processes with the ruthless, domineering methods of
fanatics. She describes these overpowering techniques in
words that are highly evocative of what the contemporary
psychoanalyst, Christopher Bollas, has called b he fascist
FOREWORD
state of mind' (Bollas, 1992, pp. 193-217). Tustin points
out that fanatics are often relatively normal and extremely
talented people. But they
treat outside people, objects and institutions as bodily
pawns on the chessboard of their 'me-centred' pur-
poses. ... This is one source of religious, sectarian
and discriminatory persecution, the aim of which is
to keep the 'nasty not-me' at bay by remaining
'blinkered' to every point of view other than their
own. Such narrow-minded affiliations masquerade as
loyalty, but they are not this in any deep sense. Like
autistic David of Chapter Three, they are mainly con-
cerned with outside surfaces. Superficial characteris-
tics like the colour of a person's skin, his political
colouring, details of his theoretical terminology, or
religious forn~sand ceremonies are seen as being
deeply significeant. They bludgeon their way through
life with global systems which aim to complete the
circle, instead of using its incompleteness as a stimu-
lus to creative endeavour. They seek to clamp their
unnaturally complete global systems on to themselves
and others. ... People who are different from them
are wicked, corrupt or abysmally wrong. The arch
manipulators who Polonius-like hide behind the arras
of their false pretensions are keeping at bay the same
terrors. All these 'normal' types of people are manipu-
lating the outside world to use it as a cloak for their
damaged vulnerability. At root, there is such a terror
of worse than death that the whole of their functioning
is based on a desperate attempt to save their own skin
at whatever the cost to other people. [pp. 82-83, this
volume]
Tustin comments further on the superficiality of signs of
kindness, empathy, and imagination.
Distribution of largesse may seem like sympathy and
kindness. Manipulation of materials, often of an ex-
tremely capable and skilful kind, may seem like crea-
tive activity. But these are not the works of creative
imagination or caring. For this to occur, the heart-
break which is at the centre of human existence has to
be experienced again and again in ever-widening con-
texts of developing maturity. [p. 83, this volume: ital-
ics added]
Conclusion:
'The Heartbreak at tlte Centre of Existence'
I shall conclude by asking the question: does theory dictate
the belief that there is a heartbreak at the centre of human
existence? Let us read again the passage from Kierke-
gaard's Fear, Trembling and Sickness Unto Death that
Tustin quotes throughout her writings:
One might say perhaps that there lives not one single
man who after all is not to some extent in despair, in
whose inmost parts there does not dwell a disquietude.
a perturbation, a discord, an anxious dread of an un-
known something, or of something he does not even
dare to make acquaintance with, dread of the possibil-
ity of life, or dread of himself, so that . . . this man is
going about and carrying a sickness of the spirit which
only rarely and in glimpses, by and with a dread
which to him is inexplicable, give evidence of its pres-
ence within. [Kierkegaard, 1941, p. 1551
The 'nameless dread' of not existing, of extinction of the
spirit, fits with the theory of norn~alprin~aryautism. At the
centre of our existence lies a divided self, a heart-break.
Throughout life, we will be shadowed by this primitive
awareness of our bodily separateness, against which no one
can fully protect us. How does this universal experience of
sickness unto death, of 'primal depression', fit with the new
interpersonal theory? Contemporary infancy theory em-
FOREWORD
braces the positive: the focus is on matching interactions,
on emotional attunement, empathy, and even states of joy
and happiness that reinforce early experiences of being
linked to a loving protector. A baby's expressions of de-
pression and despair signify some disruption or perturba-
tion in the mother-infant bond. Perhaps, though, we might
ask ourselves whether, in our theorizing, we have swung
too far the other way. Though autism is not a normal 'psy-
cho-biological' stage, though the 'interpersonal world of
the infant' lies at the heart of existence, do we not carry
with us those primal states of shock and alarm when the
world falls away and leaves us on the edge of extinction?
May 1995
REFERENCES
Anthony, E. J. (1958). An experimental approach to the psycho-
pathology of childhood autism. Brit. J. Mcd. Psych., 31: 211-
225.
Bibring, E. (1953). The mechanist11 of depression. In P. Greenson
(Ed.), Affective Disorders (pp. 13-23). New York: International
Universities Press.
Bollas. C. (1992). The fascist state of mind. In Being a Clmracter.
New York: Hill & Wang.
Bowlby. J. (1980). Loss: sadness and depression. Arrachnienr &
Loss. Vol. 3. London: Hogarth & Penguin. New York: Basic
Books.
Kanner, L. (1!943). Autistic disturbances of affective contact.
Nerv. Cliild., 2: 2 17-250.
Kierkegaard. S. (194 1). Feur, Trcn~hlingand Sickness Unto Deutlr
(tmnsl. Walter Lowrie). Princeton. NJ: Princeton University
Press.
Mahler. M. (1961). On sadness and grief in infancy and child-
hood: loss and restoration of the symbiotic love object. Psyclio-
analytic Strtdy of tlrcl Cliild, 16.
Stern. D. (1985). Tlic Interpc~rsoncll World of tlre Infant. New
York: Basic Books.
Tustin, F. (1966). A significant element in the develop~nentof
autism. J. Cliild Psycllol. & Psycliiutry, 7: 53-67.
Tustin. F. (c.1985). Professional career of Mrs. Frances Tustin.
Autobiographical account prepared for public presentation
(occnsion unknown).
Tustin. F. (1990). The Protective Shell in Children and Adults.
London: K m n c Books.
Tustin, F. (1994a). The perpetuation of an error. J. Child Psycho-
ther., 20: 3-21.
Tustin. F. (1994b). Preface to revised edition. Aulisric Barriers in
Neurotic Patients. London: Knrnnc Books.
Winnicott. D. W. (1958). Trnnsitional objects nnd trnnsitionnl
phenomena. Reprinted in Playing & Reality. London:
Tavistock Publications, 1971.
Winnicott, D. W. (1963). The mentally ill in your cnselond. In The
Maturational Processes and the Facilitating Environnrent.
New York: International Universities Press. meprinted Lon-
don: Kmnnc Books. 1990.1
xxiv
AUTISM
AND
CHILDHOOD PSYCHOSIS
AUTISM
INrecent years, as a result of the upsurge of interest in the syn-
drome described by Kanner as Early Infantik Autism, there has
been a tendency in popular speech to restrict the use ofthe term
autism to severe pathological conditions. This is not in keeping
with its use in psychological literature. More important still, it
misses the point that pathological autism seems to be an arrest
at, or regression to, an early developmentalsituationwhich has
become intensified in a rigid form. In this book autism will be
used to denote an early developmental situation, as well as
development which has gone awry.
Autism literally means living in terms of the self. To an
O~SMUGT,a child in a state of autism appears to be self-centred
since he shows little response to the outside world. However,
paradoxically, the child in such a state has little awareness of
being a 'self'.
TheAutism ofEarlyInfamy. This is a normal condition. There
is little awareness of the outside world as such, which is experi-
enced in the mode of the infant's bodily organs, processes and
zones. A normal infant emerges h m this state because of an
innate disposition to recognize patterns, similarities, repeti-
tions and continuities. These are the raw materials for such
mental processes as recognition, classification, object creation
and empathy. Through these processes, the child builds an
inner representation of commonly agreed reality and becomes
self-conscious.The study ofchildren who have failed to emerge
satisfactorily from the state of normal primary autism brings
home to us the complexity and delicacy ofthe time-consuming
process of becoming aware of the world and its objects, persons
and other minds.
The Autism Associated with Psychosis.When things have gone
grossly wrong with these early cognitive processes we say that
the child is psychotic. The degree to which he is out of touch
with reality distinguishesthe psychotic from the neurotic child.
However, it is important to make the point that the normal
healthy infant who starts life by being out of touch with reality
is not psychotic. But he is autistic.
In later chapters primary processes which seem to be associ-
ated with normal autism will be described. These are seen as
protecting the vulnerable young infant from too harsh an im-
pingement of reality. These processes seem to be the basis for
getting in touch with the outside world and other people when
sufficient capacity for differentiation has developed. Thus, it
will be seen that a concept other than primary narcissism seems
to be required. After much thought, the term autism has been
used.
As the thesis of the book develops, it will be suggested that
these normal primary autistic processes are of the nature of
sensations arising from inbuilt dispositions which as yet do not
constitute apprehension but which, given facilitating condi-
tions will lead on to this. Parental nurture provides such facili-
tating conditions. But such nurture may be grossly lacking. Or,
and this is a far more common case, the reception of nurture
may be severely blocked or confused due to some of a variety of
factors. Without, or unable to make sufficient use of nurture,
the child remainsin or regresses to a sensation-dominatedstate.
Thus, emotional and cognitive developments are either halted
or deteriorate. It will be suggested that in this state ofinanition
primary autistic processes perseverate or are reinstated. These
become over-developed and rigidly maintained. The term
pathological autism will be used to describe this state. Thus, it
will be seen that the difference between normal and patho-
logical autism is one of degree rather than kind. It might be
said that normal autism is a state ofpre-thinking, whereas path-
ological autism is a state of anti-thinking.
As the book progresses, various systems of pathological aut-
ism will be differentiated. The syndrome ofEarly Infantile Aut-
AUTISM
imr will be discussed as being associated with one system of
pathological autism, Childhood Schizophrenia as being associated
with another. This scheme of classification on the basis of the
system of autism manifested by the child seems to throw light
on treatment possibilities and techniques.
In the next chapter a primitive type of depression will be
described and illustrated by clinical material. This depression
halts normal emotional and cognitive development. In Chap-
ter Three it will be demonstrated that pathological autism
developsto deal with this depression. Winnicott's termpsychotic
defiressionwill be used to refer to it.
The final chapter will demonstrate that an understanding
of this type of depression is crucial to psychotherapy with psy-
chotic children.
Chapter T w o
PSYCHOTIC DEPRESSION
'What we Adorn see, and what b rarely described
in the literature, in the period of grief and
mourning which I believe inevitably precedes
and ushem in the complete psychotic break with
..
reality .' M A R ~ A R MAHLER,
BT 1961.
THEaim of this chapter is to describe in detail, with the

help of clinical material, the 'grief and mourning' to which
Mahler refers in the above quotation. Winnicott has termed
it psychotic depression and has distinguished it from reactive
depression which is the conscious reaction to the loss of a loved
person. Of psychotic depression Winnicott (1958, p. 222)
writes :
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 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 ofpart of
the subject. (My italics.)
Psychotic depression, sometimes termed 'primal depression',
has been found by other workers to be the 'turning point in the
arrest of emotional development' of 'atypical' (psychotic)chil-
dren (Rank & Putnam I 953).
The case material presented below is that of a child who was
diaguosed, by a very experiencedpsychiatrist, as suffering from
#arb infMhMhle
autism.
CASEMATERIAL
John's parents became worried by his lack of speech and the
fact that he seemed different from and, in most respects, slower
in developmentthan other children of his age. When aged 2 :6,
he was seen by a psychiatrist who feared mental defect. How-
ever, on being seen again six months later, John was found to
have made a small hopeful developmentin that he now put toy
motor-cars the right way up. (Previously, he had kept them
upside-down all the time in order to spin their wheels.) On the
basis of this, John was referred to another psychiatrist for a
second opinion, with early infantile autism as a possible alter-
native diagnosis. The second psychiatrist referred John (then
aged 3: 7) to the writer for intensive psychotherapy with the
following report :
There has been a failure almost h m birth to take his
milestonesin his stride, as if there were a reluctance and a
drag back at each stage. He now shows so many of the
attitudes we associatewith autism. Hischiefinterest seems
to be to tap different surfaces, or to spin round objects. He
is fascinated by mechanical moving parts, and has always
been quite clever at learning to move his body. Although
he is sure-footed he still does not feed himself; not that he
cannot-it seems as if he will not. Thisis what I mean by
jibbing at milestones. He shows excessive anxiety at times,
with days of screaming, but this aspect is much less evi-
dent. He has no useful speech, and only communicates
very tentatively by trying to use your hand. Nevertheless,
I felt sure he was capable ofmaking a primitive contact at
this sort of level, and that therefore there was something
on which one could build an attempt at therapy. My
deepest anxiety is as to whether the basic determinant of
all this may be an inherent degree of mental retardation.
'A bad family history on the paternal side' was reported.
Father's only sister was a hospitalized schizophrenicand there
were other eccentric and psychotic relatives. It was also re-
ported that there had been 'tremendous strain' between the
child's mother and an aunt who had been mainly responsible
for the care of the father during infancy and childhood. John
was a first baby. On the physical side, pregnancy and birth
were normal, but the mother, who came from a remote village
in Scotland, had been upset by what she felt to be the foreign
procedures of an English maternity hospital. She also felt that
the nurses prevented her and the baby from getting together in
a good feeding relationship. She had a great deal of milk and
was very disappointed when breast-feeding could not be estab-
lished. The baby seems to have been a poor sucker and the
mother reported that for one week after birth he did not
open his eyes. When mother and baby left hospital they went
to live with the paternal aunt. Again, the mother felt she
was prevented from getting together with her baby, this
time by the interference of the aunt. The father was work-
ing in another town for the first few months of the baby's life,
and the mother was insecure and unhappy during this time,
but her depression was not such that she had to have treat-
ment.
When I saw the parents, they reported thatJohn had had no
traumatic experiences such as separations or serious illnesses.
He had shown little reaction to the birth of his sister when aged
I :6 and had always been a quiet baby. They could give no
details about the time at which he first held up his head or sat
up, but in the locomotor sphere his development seems to have
been quite normal. They began to worry when he failed to learn
to talk, and by the strange nature of his play. Bizarre hand
movements were reported; he moved his lingers in h n t of his
face in a queer stiff way. He could not be persuaded to put
pencil or crayon to paper. Soft foods would be eaten but he
rejected hard lumps. Bowel and bladder control had not been
achieved. I had the impredon that the mother had had special
difficulty with thin aspect of child care. Remembering her own
childhood, in which she had experienced the deprivation of
living mostly away from home in an institution on the death of
her father, she spoke ofher impatience at being a child and her
longing to be grown up.
The referring psychiatrist gave intermittent but important
supportive help to the parents whilst John was in treatment.
They needed this, for when the treatment 'holding situation'
(Winnicott 1958, p. 268) was ruptured on various unfortunate
occasions,John had screaming attacks and sleeping difficulties
which they found very difficult to bear. The parents were sensi-
tive, intelligent people and it says much for their concern
for John that they maintained support for the treatment
during these times and brought him regularly. Without this,
the present relatively satisfactory result could not have been
achieved.
Course of Treatment
John was aged 3: 7 when he began treatment. At first he
came once a week, later three times, and finally five times a
week. On his first visit he was expressionless. He went past me
as if I did not exist. The one moment when this was not so
occurred in the consulting room when he pulled my hand
towards the humming top which I spun for him. At this, he
became very flushed and leaned forward to watch it spin. As
he did so, he rotated his penis through his trousers whilst his
other hand played around his mouth in circular spinning
movements. This suggested to me that he made little differenti-
ation between the movements of the top and those of his own
body. He exuded a quality of passionate, sensuous excitement.
It convinced me of the importance of maintaining the analytic
setting and interpretive procedure if I were to be gradually
distinguished from his primitive illusions, and do my work as a
therapist who helped him to come to terms with the feelings
aroused by disillusionment. From now on, I kept to a bare
minimum my compliance with the actions he pressed me to do.
I made simple interpretations, interspering them with the few
words the parents had told me he might understand. These
7
were, 'John, Mummy, Daddy, Nina (hiasister),pee-pee, baby,
potty, spin, spinning'. I repeated the interpretations in several
different ways and occasionally used actionsto supplement my
meaning (although I kept these to a minimum when I sensed
that they were interpreted by him as seductive or threatening
approaches).
The following are extracts from detailed notes which illus-
trate his response to interpretations. The first session to be
reported occurred after the Christmas holiday. (He began
treatment in November 1951.) John had no pronouns, and
this, with the limited vocabulary, makes the interpretations
sound cumbersome. Also, as all therapists know, the written
word, however vivid, often lags painfully behind the experi-
ence of rapport in the actual session.
It is important to make the point here that the sessions took
place before I was aware of Mahler's paper on the 'symbiotic
love object' (1961) or Winnicott's paper on 'psychotic depres-
sion' ( I 958). Thus, I did not impose a previously held scheme
of understanding upon the child. As I experienced it, I seemed
to flow along withJohn, surfacingwhen I felt I had understood
enough to venture an interpretation. I had been trained to
work along Kleinian lines, and those who know the work of
Melanie Klein will realize that the understandings embodied
in the interpretationsare not part of her formulations, although
they are not inconsistent with them. When I read a short paper
based on these therapeutic sessions at the Sixth International
Congress of Psychotherapy in I 964, colleaguesdrew my atten-
tion to the papers of Mahler and Winnicott. Both workers had
used a therapeutic method which had some differences from
the one I used. It is interesting that they had encountered the
same phenomena. John's sessionshave enabled me to describe
this in greater detad than I have found elsewhere. (I have
found since that some Jungian analysts have termed this 'the
place ofcritical hurt' or 'nuclear hurt'. Balint has used the term
'basic fault'. Bion uses 'psychological catastrophe'.)
8
Friday, January zoth, 1952 (Session 9)

(At this stage John came three times a week. This was the
last session of the week.)
I quote verbatim fkom my notes:
As he has done ever since his second session, he began by
playing with the humming top. On the basis of previous
material, as well as the manner of his play in this session,
I interpreted he was using his hand to spin the Tustin top
so that he could feel thatJohn was Tustin and Tustin was
John. Then he could feel that we were always together.
Immediately following this, he took out the mother
doll and handled the bead thatjoined the handbag to her
hand with the same circular movement with which he
had handled his penis in the incident with the humming
top. After tapping the mother doll, he threw her to the
ground saying very plainly 'gone'. (This was the first
word he had ever been heard to use either at home or
with me.)
(I interpreted that John was spinning the mummy's
bead as if it were his pee-pee to feel he could go right
inside the mummy's bag, but then he felt it made her
into a 'gone' mummy.)
He immediately picked up the little girl doll, turned
her round and round and ground his teeth loudly.
(I interpreted that John was spinning into the mum-
my's bag to bite the girl baby, but then he felt he made
the girl 'gone' and the mummy 'gone'.)
He took the baby doll and put it in the cot which he
turned upside down so that the baby fell out.
(I interpreted spinning into the Tustin mummy's bag
to upset her babies because he wanted to be her only
baby.)
Following this, he worked the top inside the suitcase
provided for his toys, pressing the point into some soft
plasticine strips in the bottom of it. Once he touched the
baby doll and said, 'baby' or 'pee-pee', I could not tell
which.
(I interpreted that John felt that his spinning made a
soft mummy who let him spin inside her to make her
babies gone and this made her into a 'gone' mummy.)
(During such material, I found my thoughts wander-
ing so that I was in danger of complying.with some un-
spoken request and thus behaving as if I were a part of
his body or a toy, instead of as a mature, thinking person
who was trying to help him to come to terms with his feel-
ings. Other workers have found that this is a not in-
frequent occurrence with such 'atmospheric' children.
Later, I found it helpful to interpret to him that he felt
he spun inside my head to make my brain children 'gone'
so that he could feel he could have his own way with me.)
In the above material, we see the beginning ofhis disillusion-
ment arising from the fact that I can be 'gone', both in the
sense of not attending to him and in the actual bodily sense of
being separated from him. This means I am not under his con-
trol. Four weeks later this was developed hrther when he
spoke two more words. Again it was on the last session of the
week.
Friday, Febrwry gth, 1952 (Session 23)

Mother and John had rung several times before I could
manage to get to the door to open it. As they stood on the
step they looked cold and frozen. He had stopped rattling
the letter-box; on previous occasions I had the impres-
sion that he felt he controlled me to come to the door by
doing this. He mournfully repeated 'dirty' after his
mother as she looked into his ear. In the consulting room
he tried to spin the top on the soft carpet. I t would not
spin. Violently thrusting his hand into mine he tried to
use it as an appendage to his own to make it do so. It did
not. Spitting with rage and breathing heavily, he threw
the offending top to the ceiling. It just missed the electric
light. With a crash it fell to the ground and broke into
two halves. The inside fell out. Shocked, he went to it
and said, 'Broken!' and 'Oh dear!' in a grief-stricken
way. He spent the rest of the session hopelessly trying to
mend it. I t seemed that depressing realities were pene-
trating the autism.
There now followed a confused period in the analysis (Feb-
ruary-April 1952). During this, there was the attempt to
mould people and things in a way which ran counter to their
real nature, as in the incident with the humming top. The
toys and myself seemed to be manipulated as if they were his
excreta or parts of his own body. During this time he spent
most of the sessions lying on the couch playing with his penis,
and with his own faeces and occasional bits of plasticine,
which hardly seemed to be differentiated i?om faeces. There
was also nose-picking and spitting.
Thisceased after the three-week Easter holiday (April I 952).
This was his second long break in treatment. He now deve-
loped an obsessional habit of tapping a button on a cushion
and saying 'Daddy! Daddy!' (His father was away fkom home
during this time.) This, and the toy he called 'the red daddy
bus', played a large part in the analysis during this period.
There were tantrums when he realized that they were not part
of him and so would not always do as he wanted. Following
this, he would say 'Broken ! Gone ! Oh dear!' very doleftlly
(May-June I 952). His first use of the personal pronoun came
after he had broken the 'red daddy bus' in such a tantrum. He
said, 'I mend it !I mend it !' (Session I I 8).
Monday, Noonnb~26th (Session 130)

One day, after changes in the routine of bringing him, he
was distressed when his father nearly missed his footing
on the front steps as he was waving good-bye to John
after leaving him for his session. During this session, he
seemed to be trying to maintain that the movements of
his body could keep his father alive. (For example, he
jumped up and down on the couch saying 'Daddy mend-
ed! Daddy mended!') At the end of the session when he
found that his mother and not his father was waiting for
him, he screamed, 'Daddy! Daddy gone !Daddy broken !'
Following the incident he had a severe nocturnal scream-
ing fit. In it, he said such things as 'I don't want it! Fell
down! Button broken! Don't let it bite! Don't let it
bump !'
With hindsight, I realized that these nightmare screams
expressed infantile anxieties which had been active in relation
to the father, the 'red daddy bus' and the button on the
cushion-all of which seemed to have been equated. But, as
long as the anxieties were scattered in this way, I could not
sufficiently understand them to help him to come to grips with
them.
A session which occurred fifteen months after treatment
had begun will now be reported in detail. In this session,
anxieties which had been adumbrated in previous sessions
were brought together and more clearly represented by means
of words and toys. People were now being distinguished as
people, and words were not so mixed up with material objects.
Thus the autism was much diminished.
F r i d ~January
, 25th, 1953 (Session 153)
(Before giving this session, I should say in December
John had seen a baby feeding at the breast and had
shown great interest. I had not used the word 'breast',
not knowing whether he knew it. I t now came into his
material.)
He carefully arranged four coloured pencils in the
form of a cross and said, 'Breast!' Touching his own
mouth he said, 'Button in the middle!'
(I interpreted baby John's desire to make up a breast
for himself out of his own body.)
He then put out more pencils in a hasty careless fashion
to make a ramshackle extension to the cross. To this he
said, 'Make a bigger breast! Make a bigger breast!'
(I interpreted baby John's desire to have a bigger
breast than really existed.)
He angrily knocked all the pencils so that they spread
in a higgledy-piggledy fashion over the table. He mid,
'Broken breast !'
(I interpreted his baby anger that he could not have a
breast as big as he wanted.)
He said, 'I fix it! I fix it! Hole gone! Button on! Hole
gone! Button on!'
(I interpreted his baby desire to have a breast he could
make or break as he pleased.)
He again angrily pushed the pencils all over the table
and said, 'Broken!' He then opened and shut a wooden
box with ear-splitting bangs.
(I interpreted his baby anger that he couldn't have a
breast with which he could do as he liked.)
He said, 'broken' again and went to the umbrella
stand which is in the consulting room; he put his hand
into the glove cavity which is in dark shadow. He shud-
dered and said 'No good breast! Button gone!'
(I interpreted that he felt his anger with the breast that
would not let him do as he liked with it, made him feel he
made a no-good breast a hole instead of a button.)
He went to the case and fetched a piece of dirty grey
cardboard and the crocodile. (The crocodile had been
associated with hard faeces that seemed to bite his bot-
tom.) He put them on the chest he had banged. He point-
ed to the Sellotape round the edge of the cardboard and
said 'Icy! Icy!' Then he said, 'No-good breast! Button
broken!' He slid the crocodile around the cardboard as
if it were slitheringon ice. His face went cold and pinched.
(I took up his feeling that breaking the breast made an
icy no-good breast which was no comfort to him when he
was on his own. He wanted to feel he had the button in
the button-hole.)
Now that the infantile transference was well established and

the anxieties were 'contained' in the analysis, his behaviour
outside showed great improvement. He was eager to come to
analysis and made good progress in spite of family illness,
changes in the routine of bringing him, and family bereave-
ments. 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. An unfortunate break now occurred in the 'holding
situation'.
Friday, April 5thJ1953 (Session 194)

I showed him, by means of a diagram, the day he would
come back to analysis 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 grand-parents for one week. When he
came back I was appalled. He seemed traumatized and
frozen. He had 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 babyJohn left all alone on an island' (as he
put it later).
As the bodily tensions relaxed, the night-time scream-
ing fits became such a regular occurrence that the refer-
ring psychiatrist prescribed a sleeping draught. During
the screaming fits he would hallucinate birds in various
parts of the bedroom, and say some of the phrases he had
used in his first screaming fit. The birds threatened to
peck him and were a great source of terror.
However, he gradually began to bring the infantile
anxieties back into the analysis. He again proceeded with
the differentiations he had been making ever since his
first word of 'Gone!' He related to his father in a more
real way and less in terms of a 'thing' like a button that
could be broken. He accepted that space and time separ-
ated him from me. He put experiences into such cate-
gories as 'nice' and 'nasty', and people were classified as
'naughty' or 'sensible' according to whether they did
what he wanted them to do. There was transient differen-
tiation between fact and phantasy. He would sometimes
say, 'It's a story' or, 'It's not really true'. He now told me
in more detail the illusory terrors that had given rise to
the crypticphrases in the screamingfits. (Neitherhe nor I
dismissed psychic truth, we were merely trying to estab-
lish the world of common-sense.)
He began to associate the misuse of objects with their
being broken. Of the humming top he said, 'It's broken!
Tops don't go on the carpet.' At the end of sessions he
sometimes hinted that he felt I left him because he had a
part missing or because he was a 'stinky little goat'. Some-
times he would pretend to break off his 'stinkers' (his
word for the hard faeces that cut his anus-the crocodile
of earlier material), and pretend to drop them down the
front of my dress. Sometimeshe got rid of his own feelings
of silliness by calling his father 'silly' and 'naughty', and
to his sister Nina, as to me, were assigned all the nasty
experiences he did not want himself. Thus, he demon-
strated clearly the phantasy of breaking off parts of him-
self and thrusting them into other people.
Tuesday, January o&h, 1954 (Session 360)

The connection of this phantasy with his infantile experi-
ences, and the effect on his inner world, was again shown
by play with the coloured pencils, which he arranged to
make a breast. (This was the first time he had done this
since the previous occasion eight months earlier, before
the unfortunate separation experience.) He pointed to
AUTISM A N D CHILDHOOD PSYCHOSIS
the carehlly arranged pencils and said, 'Breast !' Then,
touching his own mouth, he said, 'Button in the middle!'
Then he stood a pencil in the middle and said, 'Rocket !'
He called the whole thing a 'Firework breast'. This linked
with the drawing of a dome-shaped object with brown
and red 'stinkers' coming out of it which he afterwards
called 'Fireworks'. (Thishad been drawn following a tan-
trum when I would not let him use my hand as if it were
his own.) Holding his mouth as if it hurt, he said, 'Prick
in my mouth!' Then, 'Falls down!' ...'Button broken!'
... 'Nasty black hole in my mouth !' Then in an alarmed
way, he held his penis and said, 'Pee-pee still there?' as if
he thought it was not.
Wednesday, January ~ g t h 1954
, (Session 361)
He said of the broken humming top, 'Broken top! Nasty
peoples coming out to blow me up!' Material then came
about his 'stinkers' and piercing the button and making
'a black hole in my mouth'. I asked him about the black
hole. He answered simply, 'When naughty things are
burned they go black.' Following this, he said sadly, 'My
nice dreams turn into nasty dreams,' and then, brighten-
ing up, 'I have my nasty dreams with Tustin.' One day
the screaming fits, the cryptic phrases and some of the
previous phantasies all came together into one session.
Thursday, February 6th, 1954 (Session 367)
He was in a screaming tantrum as I opened the front door
because 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
consulting room. Without taking anything from the case
of toys, he went to the table to talk to me. He said, 'Red
button gone! It fell with a bump!' 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 trying to tell me about his fears when he fell down
just now.) Touching his own mouth he said, 'Nina's got a
black hole. She had a prick in her mouth. Button broken!
Nasty black hole!' (I should have interpreted here that
these were his own nasty experiencesof which he was rid-
ding himselfby attributing them to Nina, but I birked it.)
He took the plastic tractor which was a toy he had at-
tacked remorselessly. He touched the plastic axle which
is not in reality sharp. However, he touched it, gave a
huge shudder and said, 'Nasty hard tractor it pricks.' He
spat as though spitting something that was repugnant.
He then screwed himself up and screamed loudly. (I
reproached myself for not having attempted to put his
f&gs into words and so possibly sparing his having to
express them in violent action.) In his screaming he
pushed away flying beaks. I was afraid that he would fall
off his chair, so deviating from my usual strict analytic
procedure, I took him on my knee and interpreted
through the shrieks. The interpretations concerned his
feeling that the button was part of his mouth and the
destructive feelings he had when he found that this was
not so. He then felt he had a black hole and a nasty prick
instead of a nice button. He felt he spat nasty things into
the girl baby whom he felt took the 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 where he had equated the flying birds with
mouths.) Without the button he felt that they could hurt
him. He was afraid that he might lose his head or his penis
as he felt he had lost the button.
For two sessions after this he was afraid of certain objects in

the consulting room; one was the dark glove cavity, another
was a penis-like pipe near the ceiling; the other was the 'dirty
water bucket'. But after these sessions the night-time scream-
ing stopped. (It came back after a particularly worrying holi-
day and when the question of ending treatment was being dis-
cussed.) The hallucinations subsided and have not, so far as I
know, troubled him since.
Treatment came to an end when John was aged 6: 5. This

was earlier and more suddenly than I would have liked, but
the parents were insistent that he should finish, particularly as
his need for psychotherapy was not now so obvious. He attend-
ed a school for normal children, which reported that he was
not markedly different from other children. He was making
friends, enjoyed school, and was learning avidly. He had a
vocabulary beyond that of most children of his age but this is
not surprising since his parents were both intelligent people.
He was still a 'finicky' eater. In times ofstresshe was inclined
to stammer and to have sleeping difficulties. These remaining
symptoms made me want to continue, but, since there were
signs that he was moving into latency, and since I felt that the
parents very much wanted John to themselves, I agreed to the
cessation of treatment with the proviso that it might be advis-
able to seek further help in adolescence.
Discussion
John's Ex@rience of Gricf

Such a young child's descriptions are probably the closest
we can get to crucial experiences which occurred before he had
words or thoughts. The crux of the grief-provoking situation
was starkly expressed in his first words of 'Gone!', 'Broken!',
and 'Oh dear!' These ejaculations seemed to express evoca-
tions from his infancy when the loss and destruction of the
'button' left a 'black hole with a nasty prick'. This was John's
own formulation for the previously unformulated, intolerable
experience from which his autistic withdrawal had served as a
protection. He was now able to get sufficiently in touch with
this experience to put me in touch with it also. Being pre-verbal
it is difficult to discuss in words; evocative rather than theo-
retical language seems most appropriate.
Recalling the two sessions in which he represented the breast
with coloured pencils (Sessions I 53 and 360), it will be remem-
bered that the 'no-good breast' with the hole becomes the
'firework breast' with 'stinker' rockets planted in it by himself.
These were associated with explosive tantrum-like discharges.
In Session 360, .he confusion of the breast with his own bodily
parts is well illustrated. In these two sessions, as in Session 367,
there was the delusion (I sometimes felt it was the hallucina-
tion) of exploding away in his saliva and his faeces the 'button'
that will not be moulded by him and stay in his mouth. Like
the humming top, it is hurled away in panic and rage because
it will not do as it is told.
The connection of his own body image with his representa-
tion of a breast is again illustrated in Session 367. This was the
one in which the 'naughty' pavement got out of control and hit
him. In this session, it was clear that he felt that he had lost a
part ofhis body. In his distress he was not sure which part was
'gone'. Was it his head? His penis? Or was it that all-powerful
'button'? Had it been exploded from his body in the outburst
in which he unburdened himself? I had the impression, for
which I have no shareable evidence, that he experienced his
screams as solid, piercing objects, his mouth emitting them as
a round black hole. (In later sessions, not presented here, he
told me that he avoided looking at people's eyes 'because of
the black hole in the middle'. As these anxieties were worked
over in the analysis, he began to look at people's faces in the
way a normal child will do.)
The presented material implies that feelings in his anus are
drawn into the primary oral experience which seems to affect
every orifice of his body. His body, fretted with tender spots,
seemed to face an outside world which was pitted with black
holes. Empathic identification seemed to put me in touch with
wordless elemental dramas arising from sensations in his own
body; the 'button' being the product ofsuch bodily sensations.
The 'button'
The 'button', the loss ofwhich provokes grief, seems to be an
omnipotent illusion arising from a confusion between mother
and baby in terms of nipple-like bodily parts and substances.
Inimitably, Winnicott (1958,p. 239) puts this difficult-to-
describe situation thus :'Psychologically, the infant takes from
a breast that is part of the infant and the mother gives milk to
an infant that is part of herself. In psychology, the idea of
interchange is based on illusion.'
In theoretical language, the 'button' seems to be described
by Mahler's concept of the 'symbiotic love object'. Mahler has
postulated the 'mother-infant symbiosis' as a condition of early
infancy. In writing ot the 'separation-individuation' phase in
which, as she puts it, 'the child hatches from the symbiotic
membrane', she writes of the infant's 'grief' at the loss of what
she terms 'the symbiotic love object'. She defines this object as
a 'fusion of self and object representations'. She writes (1961,
P*341):
.. . the mental representation of the symbiotic object is
quite rigidly and permanently fixated to the primitive
representation of the self. When in the course of
maturational growth the ego is confronted with the in-
controvertible fact of separateness, the fused symbiotic
representations of self and object do not allow for pro-
gress towards individuation. We then see rage-panic
reactions . ..
I t seems feasible that John's illusion of the 'button', arising
in the state when bodily parts were scarcely differentiated,
would be formed and maintained by sensations from nipple-
like objects in his mouth and other bodily 'holes'. Hands and
mouth could feel nipple-like non-bodily objects, tongue, saliva,
lips, faeces, mucous, as well as finger-sucking, could all give
him nipple-like sensations. In my experience an important
source of the 'button' illusion seems to be the teat-tongue com-
bination.
The 'button' also seems to arise from an inbuilt nipple-
seeking pattern which took shape again during treatment.
Such an inbuilt pattern seems to be of central significance in
breast-seeking activities. Piaget's observations on young babies
complement and confirm inferences derived from psycho-
analytic material in this respect. He found that the young
infant will search for a hidden feeding-bottle if the teat is
exposed, or, for a goose or stork if the beak is exposed-that
is, nipple-like objects evoke his response (Piaget, 1954, pp. 29,
3' and 39)-
Years of intensive work with autistic children has led me to
think that such inbuilt instinctual responses are experienced
by the child as extrusions of body stuff, as a kind of pseudo-
podia which reach out into the outside world and mould and
are moulded by it. The term 'innate forms' is suggested to
describe them. These innate forms would seem to be the bodily
fore-runners oflater thoughts and phantasies. They seem to be
flexible moulds into which experience is cast, at a primitive
level of emotional development, and which are modified by
the experience so cast. When an innate form seems to coincide
with a correspondence in the outside world, the child has the
illusion that everything is synonymous and continuous with
his own body stuff. In primitive states, pattern-seeking tenden-
cies are active, but, since discrimination is minimal, any one
part of the subject's own body, or other people's bodies, or
objects in the environment, can be equated. Thus the nipple
can be felt to be a part ofJohn's body because fingers can be
equated with the innate form of nipple; the knob of the hum-
ming top could match this form; penis, tongue, 'stinkers', and
so on could all be equated with it and with each other. Such
unmodified equations led to bodily confusions which presaged
later mental ones. In this state, live and inanimate objects
were treated in almost the same way-the father could be
equated with a button on a cushion and the same things could
happen to him. In the confused period of the presented mater-
ial, it seemed that John used parts of his body, and outside
objects as ifthey were parts of body stuff, for the manipulation
ofwhat later became abstracted as mental concepts. (Much as
a child uses fingers or sticks to do arithmetical processes which
later he becomes able 'to do in his head'.)
In these early days, when the fact of his separateness from
me was forced upon him, words seemed to be experienced by
him as solid objects. When he was told about the ends of ses-
sions, or breaks in the treatment due to holidays, he winced as
if something had been stuck into him. These separations
seemed to be experienced quite concretely as broken things put
into his body. I t is difficult to know how to discuss such states,
in which the singular feature is that feelings seem to be experi-
enced as physical entities. Absence was 'goneness'-- 'goneness'
was a broken thing-'a black hole' full of a 'nasty prick'. The
observer might speak of 'depression', but for John this was a
'black hole'; 'persecution' was a 'nasty prick'; 'despair' was
felt as taking into his irreparably broken body an object felt to
be broken beyond repair. He did not 'think' about these
things; he felt he took them into his body. When the 'button'
was gone, anxieties rushed in as uncontrollable physical things.
The pain ofloss seemed to be experienced as bodily rather than
mental pain.
The 'Black Hole'

This illusion seemed to have been the significant element
which set in train his autistic withdrawal. This is what was left
when the 'button' was 'gone'. This situation is not just the
absence of 'nice' things, which intellectually we might expect
it to be. It is a situation of nasty physical presences formed in
terms of bodily substances (my words came into this category).
It is associated with things that are not under his rigid control
and so do unexpected things and bring shocks. It is associated
with the top that will not spin, my hand that will not spin it,
the 'button' that will not remain as part of his body. Panic and
rage at this frustration make him feel that the 'naughty' object
is exploded away. Rank and McNaughton (1950) report on an
'atypical' child who, after a tantrum-like explosion of panic
and rage, sobbed as she lay in her therapist's arms, 'A piece fell
out! A piece fell out!' (p. 63). When John experienced these
anxieties in the analysis, in his bodily cofision he touched his
penis as if to make sure that it was still there. This was obviously
not the castration anxiety of a neurotic child, but seems to be
an example of pseudo-phallic material associated with oral
anxieties.
The material suggests that many elements cluster around
the mouth-nipple (teat-tongue) experiences. Others may ac-
crete at later stages. Perhapsone can takethe placeof any other.
A primary classificationinto 'nice' and 'nasty' (smooth-rough ;
soft-hard ;comforting-discomforting),seems to occur at this
nodal experience. 'Niceness' is soft, smooth stuff which will be
moulded in terms of innate forms and thus seem to me a con-
tinuation of body stuff. In this state, the nipple-seekingpattern
is affirmed, but inbuilt patterns unmodified by a reasonably
firm and consistent nurturing situationlead to stereotyped and
unrealistic expectations. These expectationsseem to be experi-
enced as bodily excitation. 'Nastiness' is the hard stuff which
will not be so moulded to seem part of body stuff. That is 'not
me'. This is experienced as a break in bodily continuity-as
bodily damage-as a hole. It brings a sense ofhelplessness-a
sense of 'flop'. This gives psychotic depression its characteristic
quality.
Rank (1949) quotes and agrees with Mahler that 'affect-
motor phenomena appear to be expressions of rage' (p. &).
She also agrees with Mahler that the psychotic child's 'tan-
trum-like reaction to interruption ... seems to be one of panic
rather than rage, as if the child felt threatened by annihilation'
(p. 44).John's material suggeststhat panic and rage, expressed
in bodily explosions, were responsible for the hole being a
'black' hole. It also seems to suggest that, because subject
and object were warccly differentiated fiom each other, aa he
'annihilated' the 'naughty' object he felt threatened with
'annihilation' himself (Session 361).
Work with John also suggests that this 'black hole' formtd
as the result of frustration can be an opportunity or a threat.
Bion (1962) has shown that the critical decision for develop
ment is whether frustration is evaded or the attempt is made
to mod* it (p. 29). The autism representsJohn's attempt to
evade it. Some of the case material illustrates his attempts to
deal with it by explosive projection (Sessions 23 and 367). On
the other hand, his first words ('Gone!', 'Broken!', 'Oh dear!')
demonstrate that as soon as he developed even a limited capa-
city to tolerate the 'black hole', he was stimulated to get in
touch with his therapist as an object separate and different
from himself. (See also Sessions 153 and 360. In the light of
experiences with other children, it seems to be no coincidence
that these were sessions in which he was in touch with 'breast'
experiences.) It is obvious that getting in touch with the 'not
me' holds possibilities beyond the self, but as we have seen this
is fraught with difficulties, since something that will not be
moulded as part of body stuff becomes an inimical object as it
becomes imbued with the terror and rage it provokes. The
mother-child relationship seems important in cradling the
child through this difficult transition.
The Mother-Child Relationship
The early mother-child relationship of autistic children has
been studied by many writers; amongst these are Kanner
(1943, 194.4, Bergman and Escalona (1949), Rank and
McNaughton ( I950), Mahler (1952,1961), Rubinfine (1961)'
Meltzer (1963). Most workers seem to be agreed that con-
stitutional factors in the infant are important in the develop-
ment of autism. Tischler (1964) read a moving paper at the
Sixth International Congress of Psycho-therapy concerning
some of these mothers' heart-broken attempts to get in touch
with their inaccessible children. Meltzer (1963) writes that
these children are usually born 'in a period of parental separa-
tion and turmoil particularly characterized by depression in
the mother'. My experience confirms this.
The case-history showed that John's mother had environ-
mental difficulties which made her insecure and distressed,
and which hindered the establishmentof an on-going relation-
ship with her baby. But, in addition to these more obvious
causes of insecurity, she may have had the post-partum depres-
sion of feeling that in giving birth to her infant she had lost a
part of her body (Hayman 1962, pp. 135-9; Mahler 1963,
p. 3 I 6). Her own unresolved anxieties about such a loss, com-
bined with the fact that she had little help from her environ-
ment in bearing them, would make it difficult for her to bear
similar ones in her infant. In addition,John was an unrespon-
sive infant; it is conceivablethat, as the result ofhis weak suck-
ing, the loss of the teat might be a fairly constant feature of his
infancy. The infant's awareness of loss of the teat must bring
home to him his own helplessness to replace something that is
'gone'.
In earliest infancy, the coincidence of inbuilt patterns with
correspondencesin the outsideworld seemsto be the first 'hold-
ing situation' -'The mother places the actual breast just
where the infant is ready to create and at the right moment'
(Winnicott 1958, p. 238.) Mother and baby, teat and tongue,
work together to produce the illusion of continuity and to con-
firm it. Both Winnicott (1958, p. 238) and Milner (1955, p.
loo) have stressed the importance of ample opportunities for
such illusion in early infancy and the dangers of a premature
impingement of separateness. But coincidences are not always
exact, nor are they always forthcoming, and Bion (1961,1963)
has increased our understandingof this early situation by deli-
neating the r61e of the mother as a 'container' for her infant's
anxieties.
In earliest infancy, the infant's lack of discrimination and
the mother's adaptation arising from empathic identification
with him in the form of 'reverie' (Bion I 96 I, p. 309) serve to
minimize the explosion-producing gap between primitive
illusions and actuality. This empathic reciprocity fosters the
illusion of bodily continuity, and gradually acclimatizes the
nursing couple to the dimly apprehended fact of separateness.
It enables the mother to support her infant through the tur-
bulence arising from awareness of separateness: separateness
which seems to be experienced as a break in bodily continuity
-as a loss of a part of the body. Changes of state, for example
from 'button-in-mouth' to 'button-gone', inevitably bring ten-
sions; tensions experienced as bodily turgor, to be relieved by
bodily discharges. A mother with unbearable, unformulated
infantile insecurities, and little support in bearing them, finds
it difficult to take such 'projections' from her infant. In Winni-
cott's words, she finds it difficult to give 'freedom to the baby
to move and act and get excited' (1958, p. 310). When the
infant is a particularly anxious one, a distressing situation de-
velops. Explosions are felt to rupture the nurturing situation;
bodily tensions are felt to vapour into the 'hole' and to make it
'black'. This rupture is not felt to be 'held', healed and modi-
fied, by a responsive mother's ministrations, through the
medium of which she conveys her experience, acceptance and
understanding. Instead, the 'black hole' seems to be bandied
between mother and infant through the bodily channels of
empathic communication; breakdown of on-going processes
occurs. The infant withdraws from the mother and there is
proliferation ofpathological body-centred processes which will
be discussed in more detail in later chapters.
The capacity to sustain an insecure infant seems to be
related to the capacity to pay attention. A mother in an in-
secure and unhappy state very easily succumbs to attacks on
her capacity to pay attention to her infant-to 'hold' him in
her awareness. Such attacks may come from her own un-
resolved infantile problems, or from outside events and people,
or from her own infant, or, more usually, from a combination
of these. In the case of her own unresolved infantile problems,
as she emphatically experiencesher infant's states she becomes
pre-occupied with her own; attention is gone, her mind wan-
ders. I t seems that ifa mother, through no fault of her own, is
absent in mind, the holding situation is broken just as much
as by a traumatic bodily separation between mother and baby.
It is feasible that this 'holding situation' is affected by the
parents' relationship with each other, in that this affects the
way in which the mother responds to an infant who is the out-
come. A breakdown in the holding situation means that the
naive infant is left to bear intolerable anxieties alone. Stresses
and strains accumulate. Continuing to use his own body as if
it were the mother's, and the mother's body as if it were his
own, gives him the protection of the illusion of continuity, but
he remains undifferentiated from or confused with her. When
this omnipotent illusion is assailed, the loss of the 'button'
exposes him to the grief and terror of the 'black hole and the
nasty prick'. With little help in bearing these, the infant is
driven to increased use of sensations of his own body, with the
cumulative effects exemplified by the autism. John had be-
come more and more out of touch with ordinary human beings
who could help him, and more and more enmeshed in terrors
associated with the 'black holey-'a nameless dread' (Bion
1961,p. 309). The realistic fear of dying pales by comparison
with these agonies and terrors. As the result of these over-
whelming anxieties, John had stayed in the stage of casting
everything in terms of innate forms, equating everything with
body stuff. There was despairing longing for an over-valued,
extraordinary 'button' which seemed to become equated with
an omnipotent nipplepenis-father.
Communication
In primitive states, the 'button' seems to be experienced as
an ever-present tangible link with the mother. The material
presented in this chapter suggeststhat griefabout the breaking
of this primal nursing bond which is felt to communicate as
well as to bind, has to some extent to be worked over in the
mother-child relationship before the more normal forms of
FIG.I The large 'mother swan' was drawn first. As he drew her wings
he said: 'Its wings' (as if it were 'swings'). The duckling immediately
in front of the mother swan was 'an ugly duckling'. He had teeth. As
the other ducklings were drawn, he said that they were leading the
mother swan; the brown one was the leader.
He said: 'You have a rest at the weekend. Why?'
Following this, a t the top of the paper, he carelessly drew another
mother swan who, without a beak, was facing a bucket. He said: 'She is
up there keeping warm because she is very cold.' After this, behind the
large welldrawn mother swan he drew 'a tiny duckling who was naughty
and wandered off on his own into the wood and got lost, but the daddy
swan came and found him and this little duckling became the leader of
the ducklings'.
(John was 64 years old when he drew this picture)
communication can begin to develop. This development of
communication is related to the development of a sense of
personal identity. John's use of the personal pronoun came
when he became hopeful about mending things (Session I 18).
This 'mending' that he became able to do, albeit omnipotently,
and that he gradually began to trust me to be able to do, was
associated with being able to grieve for the 'button' and to bear
the terrors associated with its 'goneness'. He seemed to go
through primitive processes of mourning; as he relinquished
his hopes offinding the 'button' in the outside world, it became
established as a construct of his mind. This establishment of
the 'button' as the corner-stoneofJohn's psychic world seemed
to set in train communication with himself and with others.
The analytic situation gave him no actual experience of any-
thing like the 'button' (sweets, food or feeding bottles were
not provided, nor were caresses and kisses), it merely helped
him to tolerate feelings concerning its loss. The simple equip-
ment, the regularity of the sessions (in so far as this was poss-
ible), the adherence to a disciplined technique, the analytic
attention and vigilance, and the interpretations seemed to pro-
vide a 'container' (a 'cradle' as John himself expressed it), in
which John's baby self could begin to grow. Meanwhile, the
parents' sensible handling of 3+-6-year-old John was an in-
dispensable adjunct to the therapy.
Postscript
The drawing that John produced when he knew that treat-
ment was to end in two weeks' time is presented in Fig. I.
(It should be remembered that when he first started treat-
ment he had never put pencil to paper on his own. His first
marks on paper were a few lines which he did after he had
been in treatment for about a year.) The reproduced picture
was done after three years of psychotherapy. It demonstrates
John's development during treatment and gives an indication
of his good intelligence. For those versed in intensive psycho-
therapy, it will also give an indication of his emotional state
near the end of treatment. It seems to show that in times of
stress he still tends to devalue the maternal contribution to his
welfare. These attitudes to a fantasy mother mean that he
cannot make the best use ofhis actual mother. This predisposes
him to depression. However, even in this picture he shows
insight about this in that he realizes that it makes him 'lost'.
By the end of the session his arrogant controlling assertion that
the ducklings 'led the mother by the beak' was considerably
moderated. There are signs in this picture that he is coming to
grips with his eatingdifficulties, but has not yet worked through
this. Thus, althoughJohn has 'improved out of all recognition'
(to quote the family doctor), if he is to make the Mlest use of
his undoubted talents he would benefit from further help later
on.
Charpttr Three
AUTISTIC PROCESSES IN ACTION

'A neat example of a psychical system shut off
from stimuli of the external world, and able to
satisfy even its nutritional requirements autistic-
ally .. . is afforded by a bircl's egg with its food
supply unclosed in its shell.'
SIGMUND
FREUD,
1911.
I Nthe previous chapter clinical material was presented to

demonstrate the operation and origin of psychotic depression.
In the present chapter therapeutic sessions from another psy-
chotic child will be presented to demonstrate processes of
secondary autism which arise to protect against psychotic
depression (the 'hole').
CASEMATERIAL
David was referred aged I o :I o with the diagnosis of child
psychosis. The significant facts in his early history were that
David was the younger of two boys. Mother had wanted a
girl and when David was born with a slightly twisted spine,
she felt that she had a flawed child. The father had had the
same defect but it had not greatly incommoded him. This was
long before the work on the effect of early separation from the
mother had become a subject for the popular press. When
David's mother read of a masseuse in London who could cure
his physical abnormality, she decided that he should have
treatment even though it meant being separated from her
baby. With great feelings of unhappiness, she strong-mindedly
began weaning him from the breast at five months, so that at
six months he could go to London to have treatment. David
stayed in what she called a Baby Hotel from whence he went
for daily massage. The parents lived some distance from
A U T I S T I C PROCESSES I N ACTION
London and so could only visit very rarely. At thirteen months,
the masseuse decided that he needed his mother more than
he needed treatment, so he returned home with his spine
straight but with the stage set for a typical development.
When he went to the village school at five years of age, he
was found to be unteachable. From here he was sent to a
Rudolf Steiner school* and thence to a small boarding school
in London. Here, the very perceptive teacher in charge real-
ized that his learning and behaviour difficulties were likely to
be emotional and referred him to the Tavistock Clinic, aged
10:5. Tests revealed no organic abnormalities. However, the
educational psychologist found him to be untestable since he
merely drew a ruined house and was quite unresponsive to the
test items, feeling no doubt that he had drawn attention to the
crux of his problems. The teacher reported that he could not
l e a n at school and that he had outbursts of rage. These were
not like those of a brain-damaged child in that they always
seemed to be related to some frustration in the environment,
usually having to share things with other children. He was not
safe outside the house because he walked across the road un-
heeding of the traffic and often walked into trees and telegraph
poles as if they did not exist. He was very withdrawn and his
speech seemed to be for the relief of tension rather than for
communication. He was referred to me for psychotherapy,
attending four times a week.
Clinical material will now be presented to show his reactions
to separations from the treatment situation which, as can be
imagined, were always poignant. The presentation of psy-
chotic material is full of difficulties.
First, there is the perennial problem of the use of words for
what were originally non-verbal experiences. Such material
needs to be presented in an evocative rather than an argued
fashion.
Secondly, the material from psychotic patients is inevitably
A school based on the philosophy and teaching of Rudolf Steiner,
founder of the movement known as Anthroposophy.
so disconnected that it is impoeclible to put it out as a theorem
in logic. It is primitive stuff. Both child and therapist seem to
be spinning a poem, or dramatizing a play, in the attempt to
communicate about it.
Thirdly, the fact that in David's experience, subject and
object were so closely intertwined makes the material difficult
to follow and to write about.
Fourthly, David sees as analogous, objects which to our
sophisticated observation have little in common. He attends
to similarities rather than to differences, just as a young child
will equate a boiling kettle and a steam train because the
thing that is important to him is the steam, which again may
be felt to be analogous to his bodily sensations. In the
presented material David sees identities between a ball, a
boil and a breast in terms of his own bodily sensations.
His perception of the differences between them seemed to be
blurred.
Fifthly, the reader may have the same atmospheric reaction
to the material as I had. After one of these sessions, I recorded,
'I found it very difficult to concentrate in these sessions. David
talked about this and that in a seeminglyinconsequential way.
His words flowed around me like a tangible, enveloping cloak
so that I found it difficult to concentrate and to attend to their
meaning. I t was an effort to think and to speak.' I fear that
this may be the reader's experience however clearly I try to
present the material. On the other hand a certain amount of
involvement in the atmosphere of the sessions will not come
amiss. The processes exemplified by the material are diffcult
to understand other than by experiencing and working with
them. It is hoped that the material is sufficiently graphic for
such constructive involvement to take place.
Clinual Material
The material falls into two parts. Section I is concerned
with making a monster; Section I1 with making a suit of
armour. The material covers many sessions, so it has had to be
AUTISTIC PROCESSES IN ACTION
summarized. I t comes h m a time when David who was now
fourteen years old, had begun to make the journey across
London from Hampstead to South Kensington on his own.
The 'monster' material concerns his reactions to the half-term
holiday fiom school, which meant that treatment had to be
interrupted for one week for him to go to his home in the
country. Of course, by now he was much more able to tolerate
his bodily separateness from the outside world, but he pro-
vided a working demonstration of those states of relatively
minimal differentiation and ofwell-nigh absolute terror, when
he felt in imminent danger of collapse. I t is obvious that it is
only when autistic statesofinhibition and non-communication
are over that patients can communicate about what it waslike.
Thus, one of the values of David's material is that it enables us
to study autistic withdrawal from the patient's point of view. I
did not understand this material when it was first presented as
fully as I feel I do now. But bringing clinical work from a time
when I was considerably less experienced has the advantage
that the patient's material was relatively uninfluenced by the
scheme of understanding I have of it today and which I want
to develop as the theme of this chapter.
S d o n I: The MolLFtGI
As the half-term holiday drew near, David tried to live in
the illusion that he and I were linked together by an ever-
present umbilical cord which kept us in constant touch. This
cord was part of a telephone which he had made out of plasti-
cine and which signified bodily communication which bridged
the gap between us. However, this ecstatic bubble of illusion
kept being pricked. In his disillusionment, he tried to puncture
my self-confidence and enjoyment of my work. For example,
of the string I had provided in his drawer he said, 'Oh what
thin string!' My interpretationswere received with similar dis-
dain and derision. During the sessions he seemed to be in a
state of incipient rage and he said, 'Mrs Fiona (this was his
teacher) says I'm very crabby.' At other times he was 'smarmy'
and cajoling.
A few days before the holiday, he came with the remains of
a skin eruption, a boil which he had had on the second finger of
his right hand. He said that the boil had been 'a monster'. He
played with the word 'boil' and talked about 'boiling with
rage'. He asked about a 'boiler' which was in the passage out-
side the therapy room and said 'it might explodelikeavolcano'.
I had the impression that his play with words was not the pun-
ning that a neurotic child will make but that he felt that the
'clang' similarity of the words must mean that the objects
named were related in some way.
After he had talked about the boiler 'exploding like a vol-
cano', he said that Mrs Fiona had squeezed the boil and 'nasty
pus had spurted out'. He called this pus 'lava' and 'death-juice'
and went on to say, 'There's a hole all blocked up with gritty
bits of dead skin where the boil has gone.' He also said deris-
ively that Mrs Fiona had put on a healing plaster but he had
'picked it off'. (David was always picking bits of skin from his
body; his mouth and hands were often quite sore from his
picking. Sometimes he was literally stippled with holes.)
Later, he cupped his hands and said, 'It's a mouth!' Then
waggling the finger on which he had had the boil he said, 'It's
you- a puppet-midget -my tongue- I mean my finger.'
Here we see the equation of his hands with his mouth and the
illusion that I was a bad part of his body, just as his boil had
been. It will be seen from the photograph of the monster (Fig.
2) that it is like a finger with a boil on the end. The delusion
that I was so malleable that he could 'twist me round his
finger' turned me into something bad.
Later, a ball which he had in his drawer was equated with
this boil for he said, 'This ball-this boil-did you hear what
I said?' This balllboil became associated with a breast that was
also gone. As he retrieved the ball from under the couch he
said, 'Naughty thing! It's gone! Why did it go under there?'
He then addressed the ball controllingly and disparagingly
AUTISTIC PROCESSES I N ACTION
'You stay in my hands'. (It will be remembered that mouth
and hands were interchangeable,and notice the mouth on the
monster.) He went on, 'This thing full of gas! I will trap and
squeeze it and it will go off pop!' He then chanted a doggerel:
I have a little mwe
Hcr name is &#bgrg
Ipinched her in the udder
And she went o m !bang!
He then said, 'When the tits are busted they leave gritty
bits of dead skin.' (It will be remembered that the squeezed
boil had been said to leave this also.)
In the light of the above sequence, it seems legitimate to
infer that the ball was felt to be analogous to boil, breast (or
rather nipple), and myself as part of his body. Because they
were felt to be part of his body, his pent-up rage as the hint of
possible separateness impinged upon him was felt to make
them turgid with poisonous substances like a boil or a volcano.
When the inevitable explosion came, it left a hole.
David now began to cover this 'busted' ball/boil/breast/
me-as-part-of-his-body with plasticine of which he said, 'It
...
feels as if it's stuff coming out of my fingers like out of my
..
boil. spurting like stuff out of a tube ... They're tentacles.'
He covered the ball all over, also a tin to make a body. The
result ofthis envelopment with bad body stuff ('lava' or 'death-
juice') was a 'monster'. I t will be remembered that in the
beginning he had referred to his boil as being a monster. So
the wheel had come full circle. His attempt to expel the broken
thing and cover it up results in a monster. However, the cover-
ing up was not completely successful, for when the monster
was finished the dark blue ball showed black through the eye-
sockets. He said it was looking at him with 'deathly eyes'. Also
the envelopment with his body stuff meant that it became
part of his body again (see Fig. 2).
As he was leaving for the half-term holiday he looked at me
with a clear, straightforward gaze, very different from the
FIG. 2 David's monster
FIG. 3 (a) and (6) David's armour
averted dull-eyed contact during the sessions and said, 'Mrs
Fiona says I'm depressed. Is that what's the matter with me?
I just feel horrible and I don't know what to do about it. It's
my body that hurts. I've got grit all over me and I've got grit
in my mouth.' (It has been my experience that, at these levels,
the painful tension of pent-up frustration is experienced in a
bodily way as grit, gravel, prickles, tiny broken-up bits of
crunchy stuff, bits of broken glass, or some such discomforting
irritant.)
In the presented material David uses his boil and the mon-
ster aa models of processes which have become a vicious circle
and have led to a type of depression in which he feels possessed
by an evil thing. As O'Shaughnessy (1964), in her paper on
the Absent Object, said of her patient who was also function-
ing on these volcanic levels, 'Death stared him in the face.' But
yet it was worse than death. That which peers at David out of
the eyes of the monster, as out of the hollow eye-sockets of a
skull, seems to exemplify what Bion has termed a 'nameless
dread', a terror of death experienced before concepts had
developed. In so far as it is possible to put it into words, the
tenor seemed to be of violent extinction, the end of the world,
the breast being the infant's world.
David's material seems to show that as the threat of bodily
separateness impinged upon him, the blissful finger which had
been used as if it were a soft and malleable part of the mother's
body, became turgid with painful stuff. The boil is used to
express the notion of enlargement which has become painful
and so is explosively relieved. This eruption makes a hole. The
monster is the result of smearing over the hole with extruded
body stuffto make it into an enlarged and extra-ordinary part
of his body.
There seems to be an oscillation between swelling, turgidity,
explosion and collapse, the collapsed object remaining part of
the body. In the mounting panic and rage at finding that I
(the balllbreast) am separate from him, he tries to grapple it to
him. This biting and clinging is felt to be so destructive that
the object is reduced to pulp. I t is then expelled. The hole
appears again. Because he and the nipple are felt to entrap
each other as well-nigh lifeless objects, the hole afflicts them
both. A disaster separates them. The reader will be aware that
my difficulty in describing this state is due to the fact that the
pangs of separateness are experienced in a state of amoeboid
engulfing closeness.
David next tried to deal with the state of turgid tenderness
and imminent collapse exemplified by his explosive finger. He
did this by going into another body prefabricated by himself.
These processes will be demonstrated and discussed in Section
11.
Section 11: lh Suit of Amour
As David came up to the Christmas holiday following the
half-term holiday just described, he tried to wheedle a large
cardboard box out of me, as he put it, 'so that I can make a
body and dive right into it'. Later, he said it was to be a suit of
armour to protect him from 'The monster with the hole'. I did
not give him a large cardboard box but I gave him some card-
board. I t soon became clear that in managing to 'wangle' this
cardboard out of me he had experienced me as a lifeless, malle-
able thing who had allowed him to steal a march on the other
children.
From the cardboard he made a head and hand of armour.
All the time he was making the armour he was talking about
his father. He felt he plucked features from his father as if he
were a lifeless thing. For example, he said, 'Now, I'll take some
of his hair.' 'Now I'll take his ear.' 'This is his nose.' The
father was talked about as being very strong and having 'enor-
mous muscles'.
It seemed that the body he wanted to enter was that of the
father-but a father made up by himself in his own terms.
The confusing results of the entire projection of his body into
this other body were shown by what I immediately realized
was a mistake on my part. This consisted in my giving up my
seat to him. In doing this I responded to some bodily gesture
of his, that is, I responded as ifthere were bodily communica-
tion along a telephonic umbilical cord, The overt reason for
this change of seat was so that he could paint the back of the
head of the mask, something of little importance compared
with the maintenance of my proper r61e. I realized I had
behaved as a 'puppet-midget', his tongue or his finger. This
undue malleability on my part has provided us with useful
illumination concerning the projecting of himself into another
body. When we resumed our usual seats he said, 'You looked
quite different when you were sitting in my chair. You looked
like me. I expect I looked like you when I was sitting in yours.
Perhaps you are me and I am you.' This was not said as a
witticism, but quite seriously, as if he really were confused
about identities, and as if he thought that the superficial act
of changing chairs could change our identities. That it con-
fused his intellectual functioning was also shown. When he
had reached my chair he had looked far from comfortable and
had said wryly, 'Your nice warm nest that you've been sitting
on.' He then said that at Mrs Fiona's he never liked to sit on
other people's chairs, 'in case they have left a packet of lava-
tory thereY.(His baby word for faeces had been 'good-boys'.)
The next day he told me that he had made a mistake in his
school work book. It concerned 'the mother penguin's nice
brown nesting stone'.
Having finished the head, he made the armoured glove by
drawing round his own hand. Throughout the session he
seemed impenetrable, putting up a barrage of talk, some of
which concerned a story he had read about a group of animals
who lived in a pre-fab. As he left he told me that he had read a
story about a 'little tin god' which fell from its niche (see Figs.
3n and 3b).
Discussion of the 'Monster' and 'AmourJ Material
In the monshr material, an outside object is encased and
enclosed.
In the armour material, David as the subject is encased and
enclosed.
In both cases, the covered subject and object are rendered
useless and terrifying.
David becomes 'a little tin god' but he is a fallen idol. The
balllbreast seems to be both enshrined and smeared. (Omni-
potence and the fall from omnipotence are invariable features
of pathological autism.)
The enclosing and encasingprocesses were directed towards
survival in what was felt to be a desperate situation, but they
prevented psychic development.
In both pieces of material, David makes clear that infantile
experiences are active. These are talked about through the
medium of the skills and facts acquired by fourteen-year-old
David. Trying to discern infantile experiences through the
medium ofsuch material is like looking into a distorting mirror.
Account has to be taken of the distortion. In infancy, David
knew nothing of 'monsters', of 'grit' or of 'armour'. What are
some of the possible infantile equivalents?
In both sets of material bodily surfaces seem to be of para-
mount importance. I t is tenable that the 'grit' of the 'monster'
material illustrates bodily tension expressed through the skin
which has become eruptively painful, as in the boil. This
might be 'prickling with fear' and 'bristling with rage' which
has become monstrously exaggerated. The amour could
typify muscles braced ready for the spring as in a frightened
animal. Being 'stiff with terror' can be an exaggeration of this
muscular tension-an over-reaction due to a sense of over-
whelming threat. It is like the freezing of a terrified animal.
Animals invariably come into material from these levels. I t
will be remembered that David talks about a 'pre-fab' f d of
animals.
In infancy, David had had every reason for being 'petrified
with fright'. The armour which he dons with such pathetic
bravado seems likely to be the presentday equivalent of such
bodily tension. Other elements have accreted to this basic
situation.
The Suit of Armour. In this material, David was not playing
at 'dressing up' such as normal children will do, although it
had some of the same elements. He was intensely in earnest. I t
seemed to be a matter of life and death to him. By this means
he felt he got away from the monster with the 'holey-a mon-
ster which spelled out death. I t also controlled the 'grit' of his
bodily irritability and fear. Shut in the impenetrable fastness
of the armour he could neither see, hear nor touch: In-going
and out-going processes were blocked.
The 'armour' was an artefact made up by David out of arbi-
trarily selected bits of the father-a father who was used as a
'thing' to suit his autistic purposes. I t had the elements of an
impersonation but it was far more primitive. It is akin to the
echolalia of some psychotic children. They 'pick' words from
external objects as David 'picked' features from a father, and
hide themselves behind a fasade of parrotted words and
phrases. In Bettelheim's apt phrase they have contrived an
'empty fortress'. It is a 'folly' -a grim 'joke'-to hide the
heart-break of too abrupt disillusionment. The artificial voice
of the echolalic is a mockery of the real thing.
Mocking and mockery was one theme of David's material.
He derides and mocks the mother who gives him 'thin string'.
Any kindness or generosity is seen as emanating from a 'softie'
whom he can encircle and entrap with his 'smarming' ways.
But the result is a monster. He jumps out of his skin in fright.
Fearing to be made into pulp, he springs into action by seem-
ing to enter the hard body of the father. Thisfather is made up
by him which means he is a mock father. It is both a 'conceit'
and a deceit. Masquerading as a father, he fears that his down-
fall is near.
In one aspect of his global functioning he is solely concerned
with outside surfaces and his own sensations in relation to
these. It is as if, for him, the sensation of the rind of an orange
is the orange. I t has no substance apart from being seen,
touched and handled by him. The sensation of palming and
mouthing is felt to make an object exist. Not feeling it, blots it
out.
He is only aware of 'insides' as being bounded by outside
surfaces. They are hollow and empty until filled up by him.
Just as he fills a pot with his urine and faeces, so he fills the
empty vessels. The balllbreast is a 'thing full of gas' whose
existence is under his absolute control because he has filled it
and he can prick it and make it 'go off pop'. It can be inferred
that in the therapy session he similarly feels that he fills the
therapist with his voluminous talk-with his 'gassing'-his
'hot air', and can deflate her when he wants to do so. In these
global states of functioning, the 'breast' seems to be his whole
experience of 'mother', and the therapist's ear the whole ex-
perience of the therapist who is under his absolute domination.
The father can also seem to be an empty receptacle waiting to
be filled up by him, to be brought into existence bg him, for
him. He can put his own body inside that of the father, parts
of his own and his father's body seeming to be the whole ex-
perience of his body or his father's. In these states, parts of the
object seem to call the whole into existence.
Mental phenomena disturb him. They upset his autistic
expectations. They cannot seem to be made part of his body
stuff as material objects can. In his superficial and crudely
materialistic approach to the world, 'meaning' both eludes
and bothers him. The same word, for example 'boil', can have
severalmeanings. A word is not indissolublylinked to its mean-
ing nor to him. It threatens the rigid body-centred system with
which he has coped with his terrors. He has behaved in this
way because he cannot wait -waiting time is filled with mon-
strous bodily tension. Learning demands patience and he has
very little. In the metaphorical terms of the monster and the
amour, he puts his own crude construction on to things and
jumps to conclusionson the basis of extremelyslender evidence.
As an infant he had been 'let down' by external circum-
stances in a manner that was extremely abrupt and harsh. He
now seeks rigid definition of his own bodily surfaces and that
of the 'breast'. Anything not bounded by him is 'not-me' and
is dangerous. This 'not-me' was exemplified by the 'deathly
eyes' of the monster-bits of the actual ball which showed
through his autistic encasing. The 'eyes' may represent the
therapist's 'insights' which seem to see through him and his
tricks, and his own feeling that he has 'seen through' the sham
which constitutes his notion of life and living. He is dis-
illusioned. His notion that everything existed by virtue of his
endless bodily flow is disturbed by a too sudden, too sharp
awareness of a seeming break in this flow. This faces him
with the fact of death before he is sufficiently supported by
assimilated nursing experiences to cope with it sanely.
This over-definition of his own body surfaces and that of
external objects increases his feeling of 'separatedness' (aliena-
tion). He feels empty at the core. The breast had 'gone', and
his convulsive reaction to its tragic loss has made it more
'gone'. He tries desperately to arrange outside appearances to
make it seem that nothing is wrong. He shows off his 'cunning'
to divert attention, both mine and his own, from the 'broken'
breast by which he feels possessed. I t makes him feel empty,
worthless and a fool. To offset these feelings he makes 'fools'
of those who care for him. His feeling of foolishness is thus
increased.
And yet the armouring was a step forward for David. He
used remembered biu of the actual father to make his artefact,
instead of aiming at total covering up of the outside world aa
in the 'monster' material. He seemed to be telling me about
the formation of delusions-processes which are compounded
of both fact and fiction, as distinct from illusion which is all
unreality. Both are 'fictions' from which development can take
place. A 'mock up' is a basis for development work. Treating
me as a 'softie' from whom cardboard could be wheedled, and
using it to make armour, was a wangle to save his skin. For
him, this had become a chronic way of behaving, so that he
had become 'hidebound'. If he can find (and make use of)
A U T I S T I C PROCESSES I N ACTION
firmness, integrity and depth in those who care for him, his
cunning may turn into skill and finesse, and the defensive
armour develop into appropriate and adaptable responses to
the outside world. Failing this, in his state of armoured rigidity,
he is desperately at risk. From her long experience of psychotic
children, Mahler (1961)writes: 'Once their autistic armour
has been pierced they become particularly vulnerable to emo-
tional frustration, helplessness and despair.'
Gmral Discussion
This material presents us with a kaleidoscope of themes
which interpenetrate each other. Such monstrous proliferation
beyond the bounds of normal modes of expression and under-
standing is the stuff of madness. In such material, one word
can mean many things and subject and object can reverse
Ales and be one inside the other in disconcerting fashion.
There seems to be no safe ground which has reliable form and
shape. He feels bewildered.
It is a mistake at these levels to bring in the notion of intent
on the part of the child. The logic-less child behaves in certain
ways because it is in his nature to do so. There is no conscious
intent on his part. Projection (or, perhaps more precisely,
'eruption') at these levels seems to be on the model of such
reflex bodily activitiesas spitting, defecation, vomiting, cough-
ing or sneezing; activities by which an irritating, but also
exciting substance may be expelled. It is in the child's nature
to put something that is uncomfortable outside and, in doing
so, he creates a 'stink'. The 'ordinary, devoted mother' sees
this as a signal that her infant needs attention and deals with
the situation acceptingly and appropriately, i.e. she receives
his 'projections'. This can often be an outburst of temper or
tears. If such 'projections' cease the child is indeed in dire
straits. I have found that an early history of screaming and
temper tantrums are hopeful indications that treatment may
be possible. David's material illustrates projection which has
grown to pathological proportions because, at a certain early
stage, he had lacked such a devoted mother's ministrations
and, as a result, over the years he has negated such attention
as was there (for example Mrs Fiona's healing plaster).
The infantile situation seems to be that an object which had
been felt to be part of his body was suddenly found to be not so.
The 'boiling' rage about this was felt to make the object turgid
with dis-ease making stuff. It was erupted to become a threat-
ening monstrous thing. (In these omnipotent states everything
is magnified; things are blown up to be more life size.) This
exploding away is experienced as if a part is uprooted from the
subject's own body, which then seems threatened with dissolu-
tion. The foreign body which is expelled is felt to take a piece
of the subject with it. Such separation experiences appear in
dreams as a tooth being wrenched uncleanly fiom the gum.
L. P. Hartley's story of the Shrimp and the Anemone describes
such disastrous separation experiences, where untimely death
results as the soft-bodied shrimp is torn from the sucking ten-
tacles of the anemone.
One of Margaret Little's patients vividly described this
situation as a 'fracture dislocation', and went on to say 'I am
cut off from my roots' (Little 1960). From David's material
we see that certain processes have become excessive to blot out
the fact that such painful disconnectionhad ever occurred. By
this means, David tried to feel that he was indiseolubly linked
to a nurturing object which could not escape his tentacles.
These may squeeze it to death but it is still part of him, albeit
a very bad part. The ruthless attempt to possess has resulted in
his feeling 'possessed'.
David had had an actual geographical separation from his
mother, but other factors can lead to a similar sense of trau-
matic uprooting from the primal illusion of at-oneness with
the mother. Rubinfine ( I 96I ) suggests bodily illness in infancy
and disturbancein utero as being possible factors. He writes of
'premature awareness of the object as separate from the self'.
Bergman and Escalona (1949) suggest constitutional hyper-
sensitivity as a factor combined with a precocious experience
of bodily separatenessin a situationin which it was not possible
to bring 'the maternal shield against stimuli' into operation.
Winnicott (1958)writes that such children have had 'to react
too soon'. Other factors will be suggested in later chapters.
This chapter is mainly concerned with the feeling-life ofsuch a
child and his attempts to deal with psychotic depression.
Horrifling as it seems to us now that the work of Bowlby
and Robertson has brought home the disastrous results of early
separation, it was obviously still more horrifying to David. It
is impossible to know the exact details of his delusory reactions
at the time, but the clinical material tells us what they have
become over the years. Other children who have not experi-
enced geographical separation from the mother but who, for
various reasons, have come upon the fact of bodily separate-
ness in a traumatic way in early infancy, have manifested
similar features. Let us review the main features of such re-
actions.
The impact of bodily separatenessseems to have caused the
loosely integrated child to startle with fright and rage. This is
experienced as being turgid with poisonous substances and as
having 'grit'. This pressure is relieved by the explosive projec-
tion of 'lava' or 'death-juice'. The child is then faced with
'deathly eyes'-a very bad object-a 'hole all blocked up
with gritty bits of dead skin'. A security cloak made from
extruded body stuff is felt to be thrown around the 'busted'
object which thus becomes part of the loose structure of which
the child feels composed. The 'busted' object yields no hope of
integration and, as terror mounts, it is erupted again with the
same results. A deathly terror is hidden as the core of a night-
mare object. He retreats from this by leaving his own body
and entering another which he has made up for himself. It is a
cyclical manoeuvre to stop the rot.
So long as the layers of this protective 'shell' do not become
impacted beyond a point of no return, it is possible to help
such children. I have found the 'crustaceans' more possible to
help than the amoebas. The latter are passive, flaccid children
whose behaviour seems to be solely on the pattern of a reactive
physiological response, as in fits of trembling, sneezing, yawn-
ing and coughing; that is, in terms of immediate convulsive
expulsion. The 'crustaceans' have interposed a developed
piece of behaviour between a stimulus and their reaction to it.
Sucking their tongue, bubbling with their spit, jumping up
and down excitedly, flicking their fingers, tightening their
muscles are attempts to blot out awareness of a shock to which
the more flaccid child has succumbed. The crustaceans have
tried to deal with psychotic depression by encapsulation. The
tragedy is that it may result in their being permanently cut off
from ordinary life and people because they have an extra-
ordinary outside shell instead of an ordinary inside breast.
CharptGr Four
'GRIT' AND 'SECOND SKIN'

PHENOMENA
I : The 'Grit'
DAVID'Smaterial about grit in his mouth and on his body,
and similar material from other psychotic children, has meant
that papers on the Isakowtr Plunom~nonhave attracted my
attention.
This phenomenon was first described by Isakower in 1938.
The gist of the phenomenon is that something dry, soft and
gritty or wrinkled seems to fill the mouth and is felt on the
skin surface of the body to be manipulated with the fingers.
There is sometimes also a visual sensation of a shadowy mass,
indefinite and mostly round, approaching and growing enor-
mous and then shrinking to practically nothing. Isakower
associated this phenomenon with pre-dormescent states and
linked it with reminiscencesof the infant's falling asleep at the
breast when satisfied.
Spitz (1955) also associated it with satisfjing experiences at
the breast. However, both Max Stern (1961) and Benjamin
(1963) related it to situations of oral deprivation. Benjamin
..
suggests that it: '. might represent . .. a regression to an
early pathogenic fixation point.'
Stern writes (p. 209) : 'My thesis is that the described phe-
nomena do not reflect oral gratification, but rather excessive
traumatic oral frustration.' He brings much convincingclinic-
al evidence to support this statement. My own experience with
psychotic children confirms that it is associated with oral trau-
mata and with the fearing of 'falling infinitely' (Winnicott)-
fean which can be associated with falling asleep.
2 :SimilarMaterial to David's 'Suit of Amour'

The following report comes from a teacher in a day school
for Autistic Children. The teacher had not heard nor read
about David's material, nor had she read Dr Bick's paper on
the 'second skin phenomenon'. (This will be discussed in the
next section of this chapter.) She has an unusual capacity for
understanding psychotic children and for helping them to
develop. She presented the following material at a case con-
ference which I attended :
Tessa aged ten years is a pupil at a day school for

Autistic children, and has been in my class for the past
two years. Originally, I had a very fragmentary 'relation-
ship' with her, our chief contact being the creative work,
drawing, painting, sewing, and making of stuffed ani-
mals which she initiated. These were turned into learning
situations for the basic skills and language development.
At first her speech was mostly monosyllabic 'pencil', 'scis-
sors', etc., related to things she needed, but in addition
these comments, 'Tessa a boy', 'no pains in tummy', 'pull
out veins', 'eat your dinner'. These came at some time
each day with unfailing regularity, quite unrelated to
outside circumstances.
Earlier this year Tessa tried to convey to me that she
wished to make something which would cover her all
over. She started by saying 'Tessa make a doll'. I thought
she meant this literally, but when thenecessarythingswere
provided she refused them. She kept running her hands
over her face and body, but could not express anything
further verbally. I wrote asking her mother whether she
had mentioned this at home and I finally concluded that
Tessa wanted to make a doll as big as herself, that she
could get inside of. Tessa said it would be a lady doll. She
had previously shown a desire to identifL with me, by
wearing my cardigan saying that she would read, write
'GRIT' AND 'SECOND SKIN' PHENOMENA
or sew, like me. My nursery helper and I proceeded to
help Tessa to make a cardboard suit which would cover
her completely. This was rejected after being worn only
a short time, and she kept whispering 'material' to me.
The next day we found an old dress and used this
material. Although we gave her help, she sewed all day
long in a happy, hntically busy way, secretingit under
her coat to do at home in the evening. This malleable
form was much more satisfactory though she seemed
to need the experience of wearing it, only a very short
time.
Very soon after this she looked at herself in the mirror
and said, 'I've got blue eyes and brown hair' using the
personal pronoun. For several months now she has been
obsessed with people's skin, examines my arms and hands
daily, measuring her hand against mine, saying, 'Getting
bigger'. She now wants a brown skin, like some of the
coloured children in school. Her recent increased speech
and facility in language for everyday needs and personal
wishes, have made encouraging landmarks in the teach-
ing of this autistic child.*
3 : Ilic 'Second Skin Phcnommn'
Bick ( I 968) presented convincing material from many years
of infant observation and from a psychotic child to illustrate
what she termed the 'second skin phenomenon'. She suggested
that in the early infantile stage of unintegration, the parts of
the personality which are little differentiated from bodily parts
need the experience of being held together by a 'psychological
skin', the infant's own experience of his skin being important
in this regard. She suggests that this 'skin' formation occurs
when the infant has internalized sufficientlysoothing and shel-
tering experiences with the mother so that intra-psychic con-
tainment of nipple-in-mouth has been established. (In terms
I a m indebted to M k Margaret S a m p n for permission to quote
thir material.
AUTISM AND C H I L D H O O D PSYCHOSIS
of John's material, and of colloquial speech, we might say that
they need to feel 'all buttoned-up'.)
Bick described an infant whose primary nurturing con-
tainment was disturbed who demonstrated a 'muscular type
of self-containment-a second skin in place of a proper skin
container'. She also described this second skin phenomenon in
a psychotic child. David and Tessa presented particularly
vivid and clear material concerning this. I had encountered
the same phenomenon in other children. Bick's beautifidly
written paper deepened my understanding of the dynamics
of this behaviour. David's material suggested that this seems
to be the early stage of the 'False Self' described by Winnicott
( I 958) and the 'As If Personality' by Helene Deutsch ( I 949).
AUTISTIC PROCESSES: F U R T H E R
DISCUSSION
ITwill have become clear that in studying primary autism we
are studying an embryonic 'Self'. The inner sense of 'linking'
provided by satisfying experiences of encircling the nipple in
the mouth, of being encircled in the mother's arms, and of
being held within the ambience of the mother's caring atten-
tion seems to be a vital &-st step from which iategration can
begin to take place. This is integration of the various parts of
the personality, and also integration of the emergent selfinto a
situation where other 'wills' exist apart from his own. If this
sense of primal linking is lacking, processes exclusively centred
on the child's own body compensate for the lack. These be-
come a closed system for which a dog circling round itself to
catch its own tail seems an apt image. Lacking basic integrity,
and the consequentintroduction to reality, the child's develop
ment is uncontrolled and 'false'.
Entrance to normal primary autism is difficult since the
infant cannot tell us about it and we ourselves have no con-
scious recollection of it. Bion suggests an avenue of entry
through the 'reverie' of the nursing mother. Winnicott makes
the point that paradoxically, the infant only becomes aware
of the primary 'holding situation' if it is missing. Thus imply-
ing that the study of children for whom primary autism was
disturbed may throw light upon this state. As we have seen,
processes ofsecondaryautism develop instead. Difficult though
it is, investigation of pathological autism is easier than that of
normal autism.
The description of normal primary autism that follows is
based on the study of children in states of pathological autism,
on careful and detailed infant observation, and on my 'rev-
eries' as a therapist-a therapist in relation to her patients
being somewhatin the position of a nursing mother. However,
it must be remembered that in its rigidity, perseveration and
unreceptiveness pathological autism is very different from
normal primary autism.
NORMAL PRIMARY AUTISM

I t seems tenable that for the very young infant 'being' is a
stream of sensations. Put in another way, in earliest days, the
infant is the stream of sensations fiom which constructs
emerge as nameless entities. As soon as some degree ofseparate-
ness is tolerated, the infant may be said to interpret the outside
world in terms of these nameless entities which seem to be con-
stellations of sensation, at first primarily around the mouth.
Primary mouth sensations soon pick up sensations from other
body orifices for, as Spitz ( I 955) expresses it, in this undifferen-
tiated state 'overflow is the rule of the hour'.
At first it is likely that the body does not seem to exist as a
body but only as separate organs such as hands, mouth, arms,
belly. However, it seems feasible that these are experienced as
whole objects since the infant knows nothing of the various
parts being related together. To the observer, they are part
objects, but they are not likely to be so to the undifferentiated
child. At times, in the global undifferentiated states of early
functioning, he is likely to feel all mouth and all belly. The
infant's own bodily communications seem to be his primary
scheme of reference for comparison with and taking in of
objects in the outside world. We have seen that the infant's
experience of his skin seems to be of primary importance in
enabling him to feel that his bodily parts are held together
and contained. This means that he can begin to be a 'con-
tainer'.
But to realize that he has a skin, the infant must accept the
fact that the flow of his body stuff can come to an end. Prior
to this realization, the infant's whole experience seems to be
AUTISTIC PROCESSES: FURTHER DISCUSSION
in terms of his own body stuff to which an end or boundary is
not conceived. Differentiation between mother and baby and
between his own bodily parts seems likely to be minimal or
entirely absent. Innately significantparts of the caring mother
seem to be experienced in terms of these bodily zones of his
own which are in a state of excitement. In early infancy, this
is most often the infant's mouth, his own bodily parts and
those of the mother being experienced in terms of this 'primal
cavity' (Spitz 1955). Thus, as we saw in David's material, his
own hands can be experienced as a mouth (Bick 1964, Hoffer
1g4g), as also the mother's breast and the experience of her
encircling arms and certain features of her face which soon
become associated with a gestalt of the mother (Spit. 1955).
According to whether his body experiences are felt to be be-
nign or inimical, so the mother as his first representative of the
outside world would seem to appear to the infant.
In normal development, the attentive mother's responses to
the bodily communicationsof her infant arejust that bit bear-
ably different in quality from his in that she can reflect upon
her experience. She is not so full of her own cares that she
cannot help him with his. She does not empathically over-react
with being crippled by having the same pains that he has.
With the involved detachment which is sympathy she can help
to relieve them. It seems that as the mother appropriately
tends, grooms and toilets her infant, and gradually helps him
to do these things for himself, so she helps him to develop a
mind ofhis own. Eruptions of body stuff are felt to be held and
modified into something which can be formed and shaped in a
reflective way. Identification with an ordinary human being
begins to take place instead of with an extra-ordinary object
made in terms of body substances and processes. Differentia-
tions between people and 'things' are made. Thus, introjection
of and identification with a mother who can bear the pains of
bodily separatenessbegins to take place. The mother begins to
be perceived as an alive and thinking person.
Thus, the capacity for representation and the use of skills
develops. Dreams begin to take the place of random discharges
and bodily movements. Innate forms begin to be transformed
into thoughts and fantasies. The psyche as we know it begins.
The child first becomes psychologically viable and later psy-
chologically continent.
At a level suited to their age and physical development,
psychotherapy achieved this for John and David. An import-
ant aspect of this was bearing their eruptions and, when it was
possible, finding words for what had been inexpressible hor-
rors. The capacity of children to do this for themselves when
with a professional person whosejob is to help them, is astonish-
ing and humbling. Pictorial and verbal expression make the
horrors seem more manageable and less dreadful. They are
felt to be contained in a medium shared with others and this is
a support. Prior to this, such experiences have been intensely
peculiar to themselves, eccentric and relatively unshareable
by the normal modes of communication.
For this to occur in infancy, the infant has to learn to tolerate .
the fact that outside people do not always pattern themselves
in terms of a blissful completion of instinctual activities. He
has to learn to bear 'divine discontent'. In a good rearing
situation, blissful satisfaction occurs often enough for good
'linking' to become part of the infant's developing experience.
Mutual satisfactions bridge the gap between mother and in-
fant. As we have seen from the clinical material, if for any
reason the gap is not so bridged, deathly terrors rush in. The
infant not only has to bear the overwhelming experience of
lack of an important something, but frustration experienced
in explosive bodily terms means that he has to bear the experi-
ence of an extremely bad something. The lack is an insuffer-
able nightmare. Ecstatic sensations, usually covertly induced,
are a retreat from this nightmare but, when these fail, it is
increased by comparison with them. They also mean that
expectationsare fostered beyond the capacity ofhuman means
to satisfy. This leads to further frustration and the situation
becomes cumulative.
AUTISTIC PROCESSES: FURTHER DISCUSSION
Thiscumulative situation has been termed pathological secon-
dary autism. At elemental levels the completion of gestalts is of
major importance. Incompleteness cannot be tolerated; the
circle must be closed. Clinical material implies that an inner
sense of 'bristling' frustration makes waiting for the nurturing
person unbearable. As stated earlier, this increases the child's
drive to promote sensations within his own body to make it
seem 'as if' the necessary nurturing is there. Put in another
way, the child is constantly springing into action from a sense
of prickling frustration about the fact that the flow of his body
stuff seems to have come to an end. If, for reasons of her own,
the mother unduly tends to prod her child into action, the
tendency to over-react to stimuli is increased. Psychotic child-
ren have developed various ways of getting away fiom the
'prodding', both their own and other people's. In autistic
states the child is 'comfortable' for much of the time since
autistic processes produce self-satisfaction and a pseudo sense
ofself-sufficiency.This is one of the reasons why these processes
are difficult to reverse, especially ifthey have been in operation
for many years.
In the next chapter, the use by the infant and the psychotic
child of autistic objects to produce this sense of self-sufficiency,
will be discussed.
C h P h Six
AUTISTIC OBJECTS
Autistic Objects are :
(a) Parts of the child's own body.
(6) Parts of the outside world experienced by the child as if
they were his body.
In the first half of this chapter selections from a two-year
observation of a normal infant, Susan, will be presented to illus-
trate the part played by autistic objects in the child's develop
ment. This infant was observed at the same time each week
and detailed notes were made.
Observation I
Susan is two weeks old. She is always bathed on her
mother's knee. On this day she cries sharply whilst she
is lying flat on her back for her tummy to be washed.
When she lies with her tummy flat on her mother's lap
so that her back can be washed, she gives contented little
grunts. When she is again put on her back so that her
front can be powdered she starts to cry but stops as she
mouths to the breast. When she doesn't get the breast,
she starts to cry again. Finally, she stops as her fingers
and the string of her bib accidentally get into her mouth
during the threshing around she does whilst crying.
At this early stage, there seems likely to be little differentia-
tion between -thestring of her bib, her fingers and the breast.
Any awareness there is seems likely to be of the nipple, finger
and string as being part of the mouth. Thus, at this stage the
nipple is an autistic object, as the finger and string are.
In the next observation to be presented, her fist is used to
provide comforting breast-like experiences. Before this is
AUTISTIC OBJECTS
quoted, certain facts from previous observations need to be
summarized.
At eight weeks it was recorded that Susan made an m-m-m
sound whilst she sucked at the breast. At tcn weeks she was
weaned to the bottle, and throughout the records there are
notes that she made the m-m-m sound when sucking at the
bottle or her fist.
She was always bathed on her mother's lap. Throughout
the early months she nearly always cried when she was on her
back so that her front could be washed and powdered. This
often seemed to be partly because she feared the assiduous
poking which mother applied to the various nooks and cran-
nies of her body, there being more of these on the front part
of her body. However, when she was three months old she
seemed to develop a way of coping with this frightening situa-
tion.
Obsmahahonz
Susan is now three months old. Mother puts her on her
back to be powdered. She cries in a grumbling sort of way.
After a while she puts her fist in her mouth, gives a quiet
m-m-m and stops crying. As she sneezes her fist comes out
and she starts grumbling cries.
The fist seemed to be used as a comforting completion to
her mouth which enabled her to shut out unpleasant experi-
ences. I t seemed that m-m-m experiences at the breast were
becoming a continuing experience in her mind. In very threat-
ening situations she used the sensations made by her own fist
and her mouth to recall these comforting experiences. Thus,
one function of the fist as an autistic object seems to be to
revive and sustain the satisfaction of nipple-in-mouth. (The
part played by humming sounds is also implied.)
In the next piece of observation Susan used an object in the
outside world as ifit were a part ofher body to help her to bear
frightening 'not-me' experiences.
61
Observation 3
Susan is oncyear old. She is tottering round the room
on unsteady plump legs. Her mother goes into the kitchen
to make tea. Susan's eyes follow her mother to the door
and she sits down with a bump. She looks at the door
through which her mother has disappeared. However,
she soon gets up again and turning her back on the door,
picks up a large rubber ball. She cradles this in her arms
and hugs it to her chest. She then puts her lips to the ball
and totters round the room making m-m-m sounds.
When her mother returns Susan takes the ball away
from her mouth.
The manner in which Susan hugged the ball gave the im-
pression that temporarily she experienced it as being a part of
her body. Experienced as a breast which was part of herself,
she regained the illusion of having an ever-ready completion
to her mouth. However, with these last two observations we
have reached the point where the autistic object merges
into becoming the tranritional object. This important concept
was formulated by Winnicott (1958).However, Winnicott did
not make the distinction between autistic and transitional
objects which is being made here. Broadly speaking, the autistic
object is an object which is experienced as being totally 'me'.
The transitional objtct has an admixture of 'me' and 'not-me',
the child being dimly aware of this. Winnicott defined it as
'the child's k t not-me possession'.
An example of an undoubted transitional object will now
be given to illustrate the differences between this and the
autistic object.
Observation 4
Philippa aged six yearn is a tiny pale-faced little girl
who is easily overlooked in a full classroom. She never
seemed to be parted from a large dirty piece of rag which
62
AUTISTIC OBJECTS
she called her 'bibby', and her class teacher said she
sucked this rag most of the day.
As the account of the observation proceeds it becomes clear
that the 'bibby' stands for a complicated cluster of ideas. It
stands for peaches which Phiiippa wishes to bite. These in
their turn are associated with the mother's breast which she
sees when her new baby brother is fed at the breast. The
'bibby' is also her baby whom she has to comfort as well as its
comforting her. But it has other significances as is seen by the
following discussion with the observer.
0: Who is Bibby?
P: He is my baby.
0: What do you give him to eat?
P: Nothing, he feeds me. I suck him. But I am going to
boil him and eat him and get him into my tummy.
0: What will happen then?
P: He will grow into a baby.
The transitional object is distinguished by the child as being
separate from its body, the autistic object is not. The function
of the autistic object is to obviate completely any awareness of
the 'not-me' because it is felt to be unbearably threatening. I t
is to close the gap. In the child's use ofa transitional object, the
'not-me' is not completely shut out, although awareness of it
may be diminished. However, although it is possible and use-
ful to make distinctions between autistic and transitional ob-
jects, it must be remembered that these sometimes merge into
each other. We might say that some transitional objects are
more autistic than others.
Philippa's clinging to a 'bibby' at the age of six years is
somewhat abnormal. As with the autistic object, its retention
is associated with feeling 'let down' by the 'holding situation'.
However, this may not necessarily have been at such an early
age, nor have been so cataclysmic as the situation which leads
to the perseveration of autistic objects.
Some children never use transitional objects to any marked
extent. This may be because, for various reasons, they have
established very secure inner experiences of satisfjing nurtur-
ing which do not need the recurrent support and comfort of a
material object such as a teddy-bear, or piece of cloth or some
such object. However, it may also be because they have con-
tinued to use autistic objects in a compulsive way when these
are normally diminishing in importance. In such cases, most
objects in the outside world are autistic objects, that is, they
are inseparably and totally bound up with 'me'. Thus, transi-
tional experiences cannot develop to any appreciable degree.
This means that there may be a non-use of words, or other
people's words may be repeatedly echoed so that the delusion
is maintained that those 'not-me' words are part of the sub-
ject's own mouth and have thus become 'me'. There is also
non-use of the cognitive faculties in order to avoid awareness
of 'not-me'.
The autistic object as a total 'me' substance, which keeps
the threatening 'not-me' at bay is clearly illustrated in the
next observation.
Obsmahahon5
(Observer Mrs Manolson)
Matthcw was four years old and was a member of a
nursery playgroup of eight children. Matthew was kneed-
ing a fully moulded mound of dough. He said, with
fingers embracing all his dough and clutching it to his
chest, 'It's me! It's me!' Matthew lingered longest at
this play. He put the dough between his bottom and his
chair and sat upon it, thus flattening the dough into a
very large pancake shape. Then, lifting the 'pancake' on
to the table, he tried pressing the dough with one knee.
Next he leaned his tummy towards the table and, lurch-
ing forward with his feet off the ground, he pressed the
dough to the table. All this activity was wordless. Before
he left the table he put the dough through the food
AUTISTIC OBJECTS
rnincer which was clamped at the end of the table,
whispering delightedly as he did so, 'It's soft! It's
soft !'
In the full account of the observation it is striking how

differently the other children were using the dough. For W d y
it had been a loaf of bread which she cut into slices. For B w
it was a hill for his various buses. Jacob did not really use it and
stood looking at the other children.
On other occasions, M a t t h had been observed as behaving
in a 'bossy' way, trying to make the other children fit in with
his ideas of what should be done. Anything felt by him to be
soft, be it person or thing, seemed to be grist to his mill.
However, Matthew's 'pancake' and Susan's ball would seem
to fall within the relatively normal range of the use of autistic
objects. We can infer that both children needed to be some-
what controlling because of an insecure sense ofinner 'button-
ing'. (The fact that Susan's mother was afraid to release her
from her lap to put her into a bath indicates that she was
afraid to allow her to be a separate person. This must have
affected Susan's capacity to feel that she was separate h m
her mother.)
John's material in Chapter Two, gave us a vivid account of
the tumultuous feelings which have to be experienced in the
nursing situation, or its equivalent, if nipple-encircled-by-
mouth is to become an integrating element in the child's inner
world. For this to occur, the nipple as an autistic object has to
be given up. There has to be recognition of it as an object in
its own right which is separate from the mouth and which, on
occasion, has to be waited and longed-for. Normally, transi-
tional objects can help in this waiting. However, if the f m -
tration of waiting becomes intolerable, objects become used
autistically (that is, as if they are part of the body and are
the longed-for thing), and these block out frustration.
As we saw from David's material in Chapter Three, the
frustration is felt as a tangible discomforting thing-'grit'
being a common later way ofexpressing it. Diversionary sensa-
tions in bodily orifices other than the mouth can be used to
stop the mounting tension. Thus, objects held in the hand or
retained in the anus can be used as autistic objects.
To be able to give up the nipple as an autistic object, the
child has to have had sufficient time to feel that it is an omni-
potent extension to his mouth -that he has been 'born with a
silver spoon in his mouth'. As we have seen in earlier chapters,
if primary illusions are disturbed too soon, activity tends to be
deflected towards making up for autistic satisfactions which
have been felt to be insufficient. However, if the nipple re-
mains an autistic object for too long, then the pains of giving
it up are terrible. In both cases, there develops a persistent and
usually covert recourse to abnormal autistic objects. Tongues
or the soft pads of the cheeks are secretly sucked, faeces are
retained in the anus, spit is bubbled in the mouth, or a selected
object in the outside world may be tenaciously clung to, but
not used in any other way than to make it seem to be an extra-
special part of the mouth (hands and other orifices being
experienced as mouths).
The child in the next observation distressingly illustrates
this abnormal use of an autistic object, when under happier
circumstances she would have developed the use of a transi-
tional object.
Observation 6
(Observer Miss Beryl Day)
Surd was four years old. Her mother had had a mental
breakdown and there was marital disharmony, the father
being 'unfaithful'. The observer recorded :
Sarah compulsively clutched a dome-shaped shell in
her hand. She was afraid of making contact with the
other children.. She was also very stilted in using the
materials of the nursery, and would purposely select
defective materials such as broken pencils and apathetic-
AUTISTIC OBJECTS
ally try to draw with them. In this drawing she drew
'snakes doing nothing'. She drew something which she
called 'nothing going very fast'. She picked up a fawn
pencil crayon and said, 'It's not brown, it's a nothing
colour.' She drew 'spots of nothing' after having drawn a
loaf of bread which she caused to be obliterated by pencil
streaks of rain. Every time she said 'nothing' she took a
peep at her shell.
Later she wrote her name on one piece of paper which
she kept and tore a blank piece of paper which she gave
to the observer.
The observer felt that this little girl was 'driving to get help'.
This tragic little girl is clearly &aid that she is 'mentally
unhinged' ('unbuttoned') and that thus she will cease to exist
as a person. Prior to this, she must have had some shaky sense
of inner linking and of being a 'self' in order to be able to
express her fears about its threatened loss so clearly. Palming
the shell in her hand can be an attempt to revive the sensory
satisfactions of mouthing the nipple, in order to counteract
the annihilating catastrophe which she feels has occurred.
David, of Chapter Three, invariably brought a dinky car to
his sessions. I t was held in the often-sweaty hollow of his hand,
being clasped so tightly that when he dislodged it from the
flesh of his palm to show it to me, it left a deep mark. It was
felt to have powerful properties to keep catastrophe at bay
during the journey to his sessions. Like the balllnipple which
he encircled with his body stuff, he wanted to feel that it
was an extension to his body. The shell, the car, and the
balllnipple were autistic objects. They were attempts to close
the circle-to complete the all-importantnursinggestalt. Both
Sarah and David tried to create an autistic 'holding situation'
because the actual one seemed non-existent. The tragedy is
that this attempt to do something about a desperate situation
can become one in which they are helplessly trapped.
A certain type of psychotic child becomes obsessed with
hard mechanical objects like trains and cars. There may be
one to which they are so attached that if it is mislaid they
become desperate. Other children of this kind often have quite
a collection of hard mechanical toys. They do not play with
them as a normal child will do. The objects are clearly felt to
be important in keeping disaster at bay, as some adults use
amulets or charms. Such a child will often sleep with a train
beside him, as a normal child will have a teddy bear.
These children often use the hand of another person as an
autistic object. They use it as if it were without any life or
volition of its own, but was a powerful extension to their own
body to carry out their wishes. There is some recognition of
the way in which objects in the outside world operate, for the
other person's hand is used appropriately to open doors, to
switch on lights, to do up zip fasteners, etc. It is the 'not-me-
ness' of other people to which the child will not attend.
The children who use autistic objects such as the shell, the
car, mechanical objects and another person's hand have a
greater sense of bodily separateness than the normal infant
who uses autistic objects. This type of psychotic child has been
shocked into too acute a sense of bodily separateness, and func-
tions on the basis of a sharp dichotomy between 'me' and 'not-
me'. The autistic 'me' objects are to keep out the threatening
'not-me'. They are abnormal and pathological.
In the next chapter, various types of pathological autism
will be differentiated. It will be seen that the distinction
between autistic and transitional objects which has been made
in this chapter will assist classification.
SYSTEMS OF PATHOLOGICAL
AUTISM
T H E formulations which will be suggested in this and the
following chapters are based on a large quantity of observa-
tional and clinical material from which selected examples
have been quoted in previous chapters. In the present chapter
three main systems of pathological autism will be described
and differentiated from each other. A precipitating factor for
all types of pathological autism seems to be the mouth-
experienced 'hole' type of depression associated with feelings
of terror, helplessness and defectiveness. This has been termed
psychtic &pr&on. The first system of pathological autism to
be discussed will be termed Abnormal Primary Autism (A.P.A.).
Abnormal Primary Autism is an abnormal prolongation of
primary autism due to one or other of the following factors:
I. Gross lack of essential nurturing.
2. Partial lack of essential nurturing.
(a) Due to grave deficiencies in nurturing figures.
(6) Due to impediments in the child.
(c) Due to an interweaving of factors (a) and (b).
As Bowlby (1969)has emphasized, infants need other things

than the provision of food. Two of the essential ingredients in
their nurturing seem to be the provision of bearable sensory
stimulation from without, and the relief of excitements arising
from stimulation from both internal and external sources.
They also need parents, particularly a mother who has been
enabled to bear the inevitable frustrations and difficulties
associated with differentiating herself from the outside world,
and with making intra-psychic differentiations. Parents or a
marriage partner who are/is too malleable can prevent these
processes from taking place satisfactorily.
I. Gross Lack of Essmtial Nurturing
There have been instances of this in certain retrograde
institutions such as the ones described by Spitz in his film
'Grief' and Genevieve Appell in her film 'Monique'. In these
institutions the children were fed and cared for in a hygienic
fashion.In the one described by Spitz, the infants were in cur-
tained cubicles and were never taken from their cots. They
were cared for by a succession of nurses who merely fed and
toileted them. The infants were rarely, if ever, played with or
cuddled or soothed. Such gross lack of sensory stimuli from
without, and gross lack of relief of excitements from within,
resulted in marasmic states and eventual death before the age
of two-and-a-half years.
Shevrin and Toussieng ( I 965) have brought considerable
evidence concerning the deleterious effects of paucity of tactile
stimulation in institution infants. They also brought evidence
of the bad effects of too much tactile stimulation. In both cases,
the infants showed autistic-like reactions to cope with the
unrelieved irritability of the first situation and the excessive
stimulation of the second.
It is obvious that, in the institution situation, the lack of
stimulation from without would mean that the infants' aware-
ness would not be diverted from sensationsin their own bodies,
which would then be likely to be intensified to compensate for
the nurturing satisfactions they lacked. Writing from the point
ofview oflibido theory, Spitz described their psycho-pathology
as being that of an 'anaclitic depression'. In the terms of Chap-
ters Two and Three their psychopathology would be seen as
stemming from the bodily experienced 'hole' type of depres-
sion which is consequent upon projections being unmodified
by the appropriate responses of a continuing nurturing figure.
In Winnicott's terms (1958),they have had the experience of
'falling infinitely', due to the lack of an adequate material
SYSTEMS OF PATHOLOGICAL AUTISM
'holding situation'. Thishas led to their final moribund deteri-
oration.
It seems certain that any explosive outbursts of temper and
panic would be ignored and internal tensions would build up.
These children all suffered from febrile-intestinalillness which
may have been the result of their unrelieved irritability. It
seems unlikely that any of the children developed secondary
autistic processes such as those of the armoured David de-
scribed in Chapter Three. Primary autism would continue as
the result ofinadequate stimulation to provoke growing aware-
ness of the outside world. The same would seem true of family
infants who are left in cots and playpens for a great deal of the
time with very little contact with alive people.
Winnicott would say that they suffered from 'privation'
rather than 'deprivation'. He uses the termprivation to denote
a very early type of nurturing lack which occurred when 'the
essential provision was completely outside the perception and
comprehension of the infant at the time' (Winnicott 1958, p.
226). He cites (1958, p. 6) the shorter Oxford Dictionary
which quotes Burke's remark about 'privation': 'All general
privations are great because they are terrible: Vacuity, Dark-
ness, Solitude, Silence.' Such 'privations' occur so early for the
results to seem almost constitutional.
2. Partial LaGk of Essential Nurturing

Infants seem to need a good launching-pad in the form of
resilient nurturing. The personality of the child is, of course,
important and to some extent infants can make their own emo-
tional climate and bring out the best in the nurturing in-
fluences with which they are surrounded. But there are limits to
what a child can achieve in this regard, and certain features in
the mother can make for deficiencies in the essential ingredi-
ents of nurturing.
A certain type of mother and child seem to achieve only
'patchy' differentiation from each other. A clinical example
will make this clearer :
Tom, aged 2 :8, was referred to the clinic for not talk-
ing and for screaming fits when taken out of the house.
At the clinic he talked a kind of 'scribble' which only his
mother could understand. Mother and father rarely
talked to each other, and their differentiation from each
other as separate persons seemed to be hazy. Mother was
full of fears, and for the first two years of his life rarely
took Tom out of the house.
As a child, mother had been assessed as mentally sub-
normal and had had to have speech therapy. When she
was seen at the clinic she did not appear to be mentally
sub-normal. The referring paediatrician had said she was
'under-vitalized' and this was the impression she gave.
Her speech was good.
As a child, she remembered feeling very belittled by
an elder sister. She felt humiliated at having to go to the
speech therapy clinic and had had a sudden outburst of
rage there. It was felt that she must be experiencing the
same feelings with the workers at the psychotherapy
clinic. But she neither admitted this nor denied it. She
seemed passively to accept what was done.
The child would not separate from his mother and,
after wandering round the room and opening and shut-
ting all the doors he could see, he sat on his mother's knee
sucking his finger and twiddling a piece of his hair, look-
ing like an over-grown baby.
He completely failed to function in some of the Merrill-
Palmer tests, but emerged from his fog and did a few
with surprising rapidity. The ones he did were those
which involved putting shapes into holes and assembling
the parts of the manikin. As a result of this, he scored
much higher on the test than was in keeping with his
overall functioning.
Both parents, particularly the mother, seemed to have
developed a system of inertia and passivity so that issues
and differentiations were be-fogged. Their responses
seemed to be muffled. The child was following the same
pattern. When the fog was temporarily lifted and aware-
ness of bodily separateness and differentiation from the
mother impinged too unbearably, he reacted by scream-
ing. His mother was too inert to control or help him with
this. Most of the time this threat was kept at bay by his
being passive and inert.
I have come to call this type of child, an 'amoeba'.
3. Irnfdimnts in the Child
The amount of nurturing a child takes in may be impeded
by blindness, deahess, mental defect, brain damage, limp
musculature or a difficult emotional constitution. Such infants
need extra-specially good nurturing to compensate for their
impediments if they are to take in the nurturing that is
available. Nurturing which would be adequate for a normal
infant would not be adequate for them. Sometimes inborn
impediments in the child are increased by unavoidable
deficiencies in the nurturing figures. I t is not a question
of apportioning blame but of understanding the facts of the
situation.
For instance, let us consider a child with the sensory impair-
ment of blindness. In the absence of sight, awareness of bodily
separateness will develop more slowly since sight makes an
important contribution to achieving this. For example, as
hand and eye co-ordination begins to be achieved at around
the age of five months, the sighted child, as he watches the
movement of his hands, is likely to get the feeling of his body
in space. The blind child does not have this. As well as the
delay in achieving bodily separateness, lack of visual stimula-
tion means that the blind child remains body-centred much
longer than is normal. This is illustrated by the way they
interpret the outside world, at a quite late age, by analogy
with their own bodily parts. Wills (1965) has brought striking
examples of this :
Judy (6:8)Closed the lid of her Braille board saying, 'I've
closed its mouth.'
M a t t h (6:2) After telling of a bad dream, said that
when he woke from such dreams, he always felt in his bed
to see if he was 'in the mouth or not', adding that 'under
the covers its a bit like in a mouth, isn't it?'
As is to be expected, the sensory impediment of deafness is

sometimes found to be associated with autistic features, as are
mental-defect and brain-damage. It is obvious that impedi-
ments to taking in the outside world can mean that sensations
in the child's own body remain of undue significance. Also a
sensory impairment in one modality can mean that sensory
satisfactions in other modalities become of increased import-
ance. A child who is unduly sensation-centred is averted from
contact with the mother who, as an ordinary and unpredict-
able human being, can seem unsatisfactory by comparison
with the bodily satisfactions which are ever-present. Thus,
tendencies towards pathological autism are encouraged.
The degree to which sensory, muscular and cognitive im-
pairments impede on-going development will depend upon
the quality of nurturing received by the infant. Obviously, the
rearing of such infants presents many problems, and with them
an autistic mode of functioning is likely to continue long after
the time when a normal infant has differentiated its own body
from the outside world and has begun to respond to outside
influences more in terms of commonly agreed 'reality', and
less in terms of parts of their own bodies.
Satisfactory nurturing does not mean undue accommoda-
tion and compliance on the part ofthe nurturing agent, neither
does it mean a rigid and obsessional lack of adaptation. A
depressed or under-confident mother is likely to provide one
or the other of these, or else to swing from one to the other in
an inconsistent way. Children with impediments are likely to
have over-protective nurturing. Nurturing which is unduly
adaptable, and possibly seductive, is likely to lead to the child
remaining in a state of autism for an unduly long time, but
when the incontrovertiblefact of separateness impinges upon
him, it is likely to come as a painful shock. This shock is likely
to cause him to develop secondary autistic processes such as
those described in Chapter Three. Thus, Abnormal Primary
Autism (A.P.A.) can become Encapsulated Secondary Autism
(E.S.A.) if the child has the necessary inherent strength of
personality.
The infant who experiences nurturing which is rigid and
unadaptable is likely to experience bodily separateness before
he is able to bear it, and so develop secondary autistic pro-
cesses. The infant with inconsistent nurturing is likely to be
codhed in his experiencesof bodily separatenessand to resort
to body-centred hctioning to find sameness and consistency.
Winnicott's phrase 'good-enough mothering' is an apt and
usehl one. Children who do not experience nurturing which
is 'good-enough' for them are likely to develop secondary
autistic processes. For some of them, the development of these
secondary autistic processes, may have been preceded by
remaining in the stage of primary autism for an abnormally
long time.
Encap&d Secondcrry Autism (E.S.A.)

These are the 'crustaceans'. This type of autism develops as
a defence against the panic associated with unbearable bodily
separateness. In Beyond tlu Pleasure Princi'ple, Freud made
illuminatingdistinctionsbetween 'fiightY,*'fear' and 'anxiety'
He wrote as follows:
'Anxiety' describes a particular state of expecting the
danger or preparing for it, even though it may be an
unknown one. 'Fear' requires a definite object of which
to be afraid. 'Fright', however, is the name we give to
* The German word 'achreck' suggests something more drastic than
'fright'. Panic, terror, shock, horror, dread would be nearer to ita
meaning.
the state a person gets into when he has run into danger
without being prepared for it; it emphasizes the factor
of surprise.
Freud rightly says that there is something about anxiety

which protects the subject against 'fright' and suggests that
this protection is the state of being prepared. Experience
brings preparedness so that, at first, an experienced mother is
indispensable to protect her infant against fright, for she can
look ahead to avoid frightening situations or know how to
comfort him when, and if, they do occur. A preoccupied and
insecure mother does not offer an insecure infant adequate
protection. As one child patient put it, 'I expect the new baby
needa protecting with the mother's feathers after it is born so
that it doesn't get too frightened.' Metaphorically, this is what
the infant seems to need. This is not a craving to return to the
womb but a condition necessary for the infant's survival.
Infants who become autistic may have some factors in their
make-up which make them more prone to shock and to experi-
ence bodily separateness too soon and too harshly.
Thismay be due to one or more sense organs being unusually
sensitive, or to abnormally high innate general intelligence, or
to being endowed with a specific talent to an unusually high
degree. These features in the child may intertwine with fea-
tures in the parents and with environmental circumstances.
For example, there may be many moves from place to place
which upset the child, or the mother may be unduly preoccu-
pied with other concerns, or she may be depressed. A very
depressed mother finds it hard to give her infant the attention
and stimulation he needs. She becomes a 'blank' for his ele-
mental projections which remain relatively unmodified. She
is also likely to be so overwhelmed by her own frustrations and
inner tensions that she finds it difficult to help her infant to
bear his.
Likewise, a mother who is unsupported by her husband as a
result of his indifference, passivity, absence, illness or death is
likely to find it hard to give the superlative degree of attention
and support that most newly born infants seem to require.
Infants thrive best in the hands of a confident mother, and if
her poise is being continually undermined by an over-critical
husband, interfering relatives, frequent changes of habitat or
disturbing memories from her own re-evoked infantile experi-
ences, she will find it difficult to give her infant the secure
'holding' he needs. Also a mother who is averted from the
primitive aspects of herself due to depression, under confi-
dence, temperament and upbringing will find it difficult to
meet the bodily needs of her infant in an appropriate way.
She will seem to be separated fi-om him.
Some parents seem to have a too strongly developed sense
of individual definition which leads to a feeling of separated-
ness. Husband and wife pursue their own separate lives and
do not have deep ordinary encounters with each other or with
their offspring, who anyway seems to threaten their long and
carefully established scheme for coping with the outside world
and with themselves. This is often the case with professional
parents and those with creative activitieswhich are intensively
pursued. Such parents often have a cold clarity in their think-
ing and too sharp a sense of self-differentiation. This makes
it difficult for them to give appropriate transitional experi-
ences to their infant. A more ordinary mother who responds
to the outside world in a more rough-and-tumble sort of way
can do this as a matter of course. She knows intuitively when
to let her infant exploit her, and when to clamp down and
control him in relation to herself and to other people. She
allows him to be exposed to many possibilities so that he has
outlets for his feelings and his energies.
As we have seen, if the nursing ambience around the child
seems to the child to be disturbed in a catastrophic way, he
becomes traumatized. The same sensitivespot may be trauma-
tized by similar happenings. Also, the process of repetition-
compulsion which operates at these elemental levels means
that it recurs again and again. Unless it is relieved, tension
77
accumulates. The A.P.A. child has muffled his awareness of
distinctions and has under-differentiated in order to avoid his
trauma. The E.S.A. child has over-differentiated between
'me' and 'not-me', the 'not-me' being sharply shut out. This is
experienced as a barrier between him and the outside world.
It will have been obvious that the discussion of autistic
processes is fraught with semantic difficulties. For example,
the delusion of a 'shell' has had to be discussed as if it were a
material actuality. For the autistic child, it seems to be a
tangible, enveloping thing but we, as sophisticated observers,
know that it is a primitive construct of the naive mind which
nevertheless exerts a powerful influence.
Autistic barriers will be discussed in detail in the next
chapter. In this chapter patterns of behaviour which are
characteristic of psychotic children will be discussed and an
attempt made to understand their function.
Many psychotic children spin their bodies and outside
objects as if they were their bodies. These stereotyped, repeti-
tive activities give such children the sameness and security
that they crave. This seems to be because, at a certain point
in infancy, changes occurred which were too sudden and too
upsetting for them. Changes brought the terrifying experience
of bodily separateness and are to be avoided. The spinning
also seems to have another function. By concentrating the
whole of their attention on the spinning, they avoid the fright-
ening 'not-me' aspects of the outside world. It also seems feas-
ible that the spinning may serve the purpose of producing a
state of dissociation, akin to self-hypnosis, whereby the fight-
ening 'not-me' objects are felt to be blacked out. In watching
the trance states provoked by the ritual dancing practised by
primitive tribes, I have often been reminded of the spinning
of an autistic child. These trance dances are often aimed at
exorcising bad objects from the body or from the surroundings,
just as the autistic child's spinning seems to be directed
towards this. In other words, it ia an attempt to blot out
consciousness.
Animism and autism seem to be opposite modes of opera-
tion of the primitive mind. Animism consists of endowing
objects with life; pathological autism is a death-dealing pro-
cess which blocks out things with body stuff to make them
non-existent. It also reduces alive people to the state ofinanim-
ate things. Distinguishing between alive and non-living objects
would seem to be a critical stage in the development of the
child (Spitz, 1963). In pathological autism this distinction
either has not been made with any clarity (A.P.A.), or has
been blotted out (E.S.A.).
Clinical material indicates that in situations of insecure
nurturing (due to impedances in both mother and child) the
nipple-tongue assumes undue importance. I t seems tenable
that in normal development this is felt to bridge the gap
between mother and child. If awareness of loss of the nipple is
experienced before the capacity for inner representation of
absent objects has developed, this bridge is felt to be broken.
This seems to have happened to the autistic child who wants
to avoid any repetition of the painful experience. Many E.S.A.
children suck their tongues and the soft pads of their cheeks.
Others find comfort from the sensation of the mass of faeces
in the anus. Thus, they protect themselves from ever experi-
encing the loss of the mother in tangible, hole-comforting
form.
Autistic objects, unless they are over-used or used for an
unduly long time, play an important part in enabling children
to deal with their feelings about the loss of the mother. A.P.A.
children resort to primary objects long after the time when
these are normally given up. Such mouth-comforting activi-
ties seem to be based on primary inbuilt dispositions, for
children in the womb have been photographed with their
fingers in their mouths. The tongue and cheek-sucking of the
E.S.A. child seems to be a deviant pattern.
Clinical material also indicates that the beating of the
child's own heart has been important to him when he was
lonely and frightened. This may be because the pulsing rhythm
of the nipple in the mouth becomes associated with the beating
of the heart, or it may be because the suckling has an inbuilt
sensitivity to the beating of the mother's heart and so turns to
the beating of his own heart to feel that mother is there:
Mother may leave but the beating of his own heart and the
pulsing rhythm of his sucking can always be with him. These
are mechanical and predictable, unlike mother who by her
sudden and unpredictable absences can precipitate fright.
Laing writes that adult schizophrenics have a heart-break at
the centre of their being. Work with psychotic children seems
to enable us to be in touch with the primal mouth catastrophe
from which the heart-break is a derivative. All these parts of
the body, tongue, cheeks, faeces, heart are more closely part
of the child than pa* ofthe hand which have to move through
space to be comforting. This may have something to do with
their abnormal use by children who are excessively defended
against experiencing any form of bodily separateness.
In normal development, the mother seems to be able to
allow her infant to have a 'salting' of the terror associated with
bodily separateness so that he can gradually develop a pre-
paredness for that situation. Part of this preparedness is the
capacity to hold an image of the absent mother in the mind so
that both mother and infant are freed from the necessity for
constant bodily contact. As we have seen, autistic children
have never reached this stage, constant bodily contact is
demanded, and the illusion that it is present is maintained by
autistic activities which impede the use of the actual mother.
The real mother is negated as a source of 'not-me' dread and
so she is prevented from giving the nurturing of which she is
capable.
This is naturally a source of deep distress to the mother who
often becomes more and more insecure in her rearing of this
child who constantly rebuffs her overtures. As those of us
know who have encountered such children in the therapeutic
or educational situation, the attempt to make contact with
them is very tiring, distressing and disturbing. It is the tragedy
of this situation that something which seems to have started
as a somewhat temporary recoil in panic, has become exacerb-
ated as the yean have gone by. This is to such a degree that it
often seems irreversible.
The trouble with the E.S.A. type of autism is that the situa-
tion gets worse and worse because it cuts off access to outside
influences which alone can modifL it. This is nobody's 'fault',
and much damage has been done and unnecessary hurt caused
by the implication that the mothers of autistic children are the
sole sourceof their child's troubles. For a compaasionate under-
standing of what these mothers have suffered in their attempts
to get in touch with their unresponsive children, the reader is
r d e ~ e dto Tischler's papers (1964). He makes the very rele-
vant point that by the time clinicians see these mothers they
have been subjected to much emotional stress. Their children
can, as therapists know, be very demoralizing.
Psychotherapeutic experience leads me to the conclusion
that in many neurotic children chronic processes of the E.S.A.
type have been isolated to a 'pocket' of functioning, so that
development seems to continue normally and the 'pocket' of
encapsulation gives trouble later. This may be in the form of
phobias, sleeping difficultia, anorcxiu mosa, elective mutism,
someskin troubles, somepsycho-somaticdisorders, some learn-
ing difficulties, some speech disorders and some form of de-
linquency. In this 'pocket', autistic objects have maintained
their ascendancy, and transitionalobject phenomena have not
developed to any significant extent. There is imagination of
a primitive type, but this is limited to play around bodily
objects and their equivalents in the outside world.
This type of autism also seems to be at work in the character
structure of some relatively normal individuals. Rubinfine
(1961) has suggested that negation, which is characteristic of
this type of autism, is the fore-runner to h i d . Denial is a
major mode of defence of the hypo-manic character. When the
iron-clad E.S.A. children come out of their autism there are
invariably manic-depressive mood swing8 between the ecstasy
of omnipotence and the 'flop' of despair. The latter resulting
from the often-submerged tantrums which occur when objects
which have been experienced as 'me' are found to be 'not-me'
after all.
Some relatively normal and often extremely talented people
treat outside people, objects and institutions as bodily pawns
on the chessboard of their 'me-centred' purposes. Of such stuff
fanatics are made. This is one source of religious, sectarian
and discriminatory persecution, the aim of which is to keep
the 'nasty not-me' at bay by remaining 'blinkered' to every
point of view other than their own. Such narrow-minded
affiliations masquerade as loyalty, but they are not this in any
deep sense. Like autistic David of Chapter Three, they are
mainly concerned with outside surfaces. Superficialcharacter-
istics like the colour of a person's skin, his political colouring,
details of his theoretical terminology, or religious forms and
ceremonies are seen as being deeply significant. Such formal-
ists stamp on the original and the new. They bludgeon their
way through life with global systems which aim to complete
the circle, instead of using its incompleteness as a stimulus to
creative endeavour. They seek to clamp their unnaturally
complete global systems on to themselves and others. There is
no room for individual movement and difference. It also falsi-
fies and makes unreal their own responses and their views of
other people. People who are different from them are wicked,
corrupt or abysmally wrong.
The arch manipulators who polonius-like hide behind the
arras of their false pretensions are keeping at bay the same
terrors. As are the persistent chameleons who lacking inner
principles take on and talk in terms of the colour of their
surroundings. Or the ambitious mediocrities who take over
ideas lock, stock and barrel (with no acknowledgement to the
originator), and use them in a dogmatic or chaotic fashion.
All these 'normal' types of people are manipulating the outside
world to use it as a cloak for their damaged vulnerability. At
root, there is such a terror of worse than death that the whole
of their functioning is based on a desperate attempt to save
their own skin at whatever the cost to other people.
In moments of insight such characters feel impatient with
the glaze of artificiality which prevents their being in touch
with people as they are. They feel that they are for ever clam-
bering up the looking-glass to get to the other side where
objects are depicted frcsh and not at second-hand. In the
'through the looking-glass' world, there is little originality,
creativity or sympathy, since for these to develop there has to
be awareness of the separateness of other people whose
difference is respected and valued. There also has to be keen
awareness of the difference between things and people.
Distribution of largesse may seem like sympathy and kind-
ness. Manipulation of materials, often of an extremely capable
and s W kind, may seem like creative activity. But these are
not the works of creative imagination or caring. For this to
occur, the heart-break which is at the centre of human exist-
ence has to be experienced again and again in ever-widening
contextsofdevelopingmaturity. The care ofpsychoticchildren
demands people who have experienced this.
Psychotics are not a different animal from ourselves. It is
tenable that most so-called 'normal' individuals have vestiges
of pathological autism at the root of their being. Since growth
is not a smooth-flowing process but goes in jumps, the realiza-
tion of bodily separatenessis likely to be a shock to all infants.
Integrations are likely to take place which bring the fact of
bodily separatenessinto the focus of the infant's attention in a
sudden and incontrovertible way. This brings with it the des-
pair about replacing something that is 'gone'. That which is
'gone' becomes an inimical 'not-me' void to be avoided by all
the forces at the child's command. The fact that this avoidance
creates further voids is the tragedy of pathological autism.
However, in normal development there is sufficiently strong
reaching out on the part of the infant, and sufficiently strong
response on the part of the mother supported by the father,
for the infant to be able to tolerate the void without avoiding
it and being thrown back into an inanimate world of people
and things which are not differentiated from body stuff. How-
ever, there seems to remain in the depths of all of us (or in
some of us), vestiges of comfort-seeking autistic inertia which
exert a backward pull. Freud seem to have been referring to
this when, in Bgond t h Pleasure Princi'pk, he wrote of the pull
to return to the inanimate which he associated with his concept
of the Death Instinct. How this backward pull is dealt with
seems to be significant for normal development.
The autism that has been discussed so far has been asaoci-
ated with an mest of mental development. A type of autism
will now be discussed which is associated with regression.
Regression to Secondary A u h (R.S.A.)
In aome pathological conditions, on-going development
seems to have taken place but on a very insecure basis. This is
because a large part of the personality has remained autistic
and out of touch with nurturing Muences whose bodily
separatenesswas recognized. This is often a situation in which
there has been undue adaptation, and possibly unduly seduc-
tive responses on the mother's part. However, these infants
often seem to be unduly passive and to have a weak drive to
integration. This is the kind of situation which leads to the
'too-good' baby type of history. A time comes when this too-
good adaptation of mother and infant to each other (a 'model'
baby and a 'model' mother) can no longer be sustained. The
infant's development, which has been based on an artificial
relationship, breaks down and there is regression of the part
of the personality which has achieved tenuous development.
Some remnants of this later development, such as fantasies,
seem to be retained to be drawn into the autistic sensation-
centred functioning. A salient differential characteristic of
this regressive type of autism is the retreat into fantasies
closely associated with bodily sensations. E.S.A. has little
fantasy.
A type of autism asllociated with a primitive fantasy life has
been described as being characteristic of adult schizophrenia
(Bleuler, I 913). Thus, it would seem to make for simplicity if
the term childhood schizofihrenia were reserved for children who
manifest this regressive type of autism. Adult childhood schizo-
phrenia would then have in common that in both of them there
are :
(a) Fantasies
(b) Breakdown after what looks like normal development.
This would also fall into line with Rimland's differential
diagnosis between Early Infantile A u h and Childhood Schko-
phrcniu (Rimland 1962).I t would make for more reliable diag-
nosis in psychotic statesifthe child were seen for at least twenty
diagnostic interviews in a psychotherapeutic setting with a
clinician trained in depth analysis. These children present
such multifarious behaviour pictures that it is only after ex-
ploration in depth that common factors can be brought
together for some sort of rough diagnosis, in terms of types of
autism to be possible.
Comparison Between R.S.A., E.S.A. and A.P.A.
The outstanding psychotic syndrome associated with Re-
gressive SecondaryAutism (R.S.A.) is Childhood Schizophrenia.*
The outstanding psychotic syndrome associated with En-
capsulated Secondary Autism (E.S.A.) is Early Infantile
Autism.
In R.S.A. before the regression, the child had the aware-
ness of bodily separateness for a longer period of time than
E.S.A. children have had. E.S.A. children have experienced
it too painfully, have erupted and then made a barrier against
experiencing it again. A.P.A. children seem hardly to have
experienced it at all, save in short bursts when they reacted
eruptively but in no other active way.
R.S.A. is associated with disintegration, whereas E.S.A. is
* An addendum to thin chapter differentiatea between two typer of
Rcgrcuive Secondary Autiun.
associated with hasty 'integration' from a state of unintegra-
tion. A.P.A. children have integrated in some areas, but for
the most part have kept differentiations blurred.
In R.S.A., excessive splitting processes finally result in frag-
mentation of object and ego. E.S.A. children react globally;
there is a simple dichotomy between pleasure-giving 'me' and
uncomfortable 'not-me', the latter being obliterated. In A.P.A.
distinctions are blurred.
In E.S.A., encapsulation processes are an intensification of
normal processes of extrusive and intrusive envelopment.
R.S.A. is associated with an overdevelopment of the pro-
cesses termed by KleinpojGctive idcntijication-an unfortunate
term as she well realized. She defines it (1963,p. 58) as follows:
'Identification by projection implies a combinationof splitting
off parts of the self and projecting them on to (or rather into)
another person.'
Difficulties in understanding this concept would seem to
come from the confusion of subject and object which is intrinsic
to ita nature. It would seem to be a useful concept since it pro-
vides a scientific description of the 'dialogue' (Spitz 1963)
between mother and infant, which otherwise seems 'quasi-
mystical' (Rank 1949, p. 43). These processes, in their normal
aspects, seem to be a dialectic or feed-back system of illusion,
the to-and-fro of which makes it seem that bodily eruptions of
fiight and rage are contained and made bearable. It is a kind
of empathic reciprocity. Tones of voice, muscular tensions,
facial expressions, bodily postures and behaviour are the chan-
nels through which such communications are received. They
are the non-verbal means whereby we stand in each other's
shoes, by which we understand each other. It is only when
parts of the selfseem to be minutely fragmented (disintegrated)
and dispersed over a wide area, using many separate reposi-
tories, that these processes become pathological. The degree
of scatter of these relegated parts influences the hope of out-
come from psychotherapeutic treatment.
In their pathological manifestations, the processes of pro-
jective identification seem to have much in common with 'dis-
tancing' and 'externalization' as described by W. M. Brodey
(1965).Mahler (1952)uses the term 'symbiosis' to describe
the mutually beneficial nurturing situation; when it gets out
of control and becomes pathological she terms it 'symbiotic
psychosis'. Winnicott (1958)refen to a situation of 'double
dependence' in early infancy and warns us that 'the notion of
interchange is based on illusion'.
Many A.P.A. children seem to have been prevented by the
mother from making normal differentiations. They seem to
have achieved this in patches. This limitation of differentiation
seems to be due to acute anxiety on the mother's part of allow-
ing the baby to be separate from herself. The infant 'picks up'
the mother's fear ofseparateness, and 'plays into' the situation.
The E.S.A. children seem to have wrapped themselves up
tightly in order to deal with the oral trauma of the loss of
primal unity with the mother. They are 'wrapped up in them-
selves', outside objects being experienced as part of their body.
The R.S.A. children have differentiated from the mother in
a precarious way and then have retreated to being 'wrapped
up in the mother', as the mouth trauma of bodily separateness
proved too much for them.
As regards cognitive development: the A.P.A. children have
'islands' of cognitive functioning. The negation of the outside
world on the part of the E.S.A. child results in inhibition of
thinking. In the R.S.A. child fragmentation and extreme con-
fusion of parts of the self with those of other people, results in
disintegrated and confused thinking.
As regards the mother-child relationship: the A.P.A. child
scarcely differentiatesthe mother from himelf(his body). The
E.S.A. child makes her into 'nothing' or into non-sense. The
R.S.A. child feels that she is a 'muddle'.
As regards speech : this may be very limited or be 'scribble'
in the A.P.A. children. Many E.S.A. children are mute, echo-
lalic, or have their own private language; those children who
have developed speech seem to use it for the relief of tension
rather than for communication. In the R.S.A. children,
speech is often slurred or ill-formed, or it may be prolix and
confused in meaning. Body movements may be clumsy in con-
trast to the preternaturally nimble and feather-light move-
ments of the children manifesting early infantile autism. The
ethereal quality of these latter children is missing. The eyes of
the regressed children are often unfocused and blurred like
those of an old man, and they seem to look through, rather than
at people. Some of the E.S.A. children avoid 'looking at'
altogether.
The comparative features of the four types of autism will
now be summarized by means of two charts. Chart I will deal
with precipitating factors, Chart I1 with differential features.
These charts embody hypotheses concerning autism, which
can be confirmed, modified or discarded in the light of other
people's experience. The virtue of these hypotheses, as far as I
am concerned, is that they provide an integrative scheme
based on child development, which covers the facts as I have
encountered them during the psycho-analytic treatment of a
wide range of emotional disorders.
Addendum
Further work has caused me to differentiate two types of
R c g ~ ~ s sAutism
i v ~ which will be termed R.S.A. ( I ) and R.S.A.(2)
respectively. The first stages of Regressive Secondary Autism
are the same as those leading to Encapsulated Secondary
Autism: Encountering the fact of bodily separatenessfrom the
mother causes a distinction to be made between 'me' and 'not-
me'- 'known' and 'not-known' -'familiar' and 'stranger'.
For some of a variety of reasons the 'not-me, not-known
stranger' is too terrifjing to be tolerated. The E.S.A. child deals
with this situation by encapsulation.This means that awareness
of separateness is completely blotted out. The R.S.A. child has
a dim awareness of separateness and deals with it by dispersal
of bits of himself into bits of outside objects which are used as
ultra-protective coverings. If the dispersal has not been too
SYSTEMS O F PATHOLOGICAL A U T I S M
fiagrnenting or has not continued too long, it is termed
R.S.A. (I). These are usually young children and are treat-
able by the type of psychotherapy to be described later. If left
untreated, fragmented scattering leads to deterioration since
processes of encapsulation do not protect against this. (Spon-
taneous recoveries which may take place in E.S.A. children
are not so possible in the R.S.A.(n) conditions because the
deterioration soon becomes irreversible.)
TYPES O F AUTISM
Types of A u h : Precipitating FoGtors
-
-
Normal Abnormal Encapsulated Regressive

Primary Autism Primary Autism Secondary Autism Secondary Autism
(N.P.A.) (A.P.A.) (E.S.A.) (R.S.A.)
' X iX d Sol- Abnormal PivrOngaiion of Pn'nqy Inhibition as a D Q k a Regression as a Dsfaw
A&
(Anthony's term, 1958) This may be due to: Nurturing is negated due to Insecure on-going development
separation trauma-processes of breaks down under stress.
encapsulation (intasificd Exccasive use of projective
w
h) envelopment) lead to child identification result in mother
becoming 'wrapped up in and child becoming wrapped up
hima&",that is, he uses outside in each other.
objecta as if they were himself. On-going development may be
Separation-trauma can be due instcure owing to a combination
to a combination of the following of the following facton :
b n :
I. The 1 capacity h r I. Gms lack ofunsory I. Abnormal prolongation of I. Thue has been abnormal
. . .. -
dncnmmation and for stimulation as in certain primary autism which means prolongation of primary
making differentiations, retrograde institutions. that when awareness of autism followed by some
chmctabtic of early h h c y bodily separateness docs on-going development which
m m that them is little impinge, it is a shock for disintegrates under stress of
awaremas of the outside which the child is awareness of bodily
world. unp=pared- separateness.
2. As discrimination increases, 2. Partial lack of sensory 2. Geographical q a r a t i o n from 2. There can have been
autistic processes of flowing- stimulation due to : the mother when use of temporary arrest in E.S.A.
over-envelopment-at- (a) Impediments in the child autistic objects is at its height. followed by some on-going
oneness protect the infant's such as blindness, deafness, development which breaks
illusion that bodily brain-damage, some forms of down under stress.
separateness has not taken mental subnormality or weak
place. Response to outside musculature.
world is autistic. (b) &ing left alone a great deal.
Little attention from
nurturing adults.
3. The 'ordinary devoted 3. Mother (parents) who are 3. Bodily illness in early 3. An unduly adaptive
mother' receives her infant's under-differentiated due to infoncy. environment masks the
'eruptions' and helps him innate defects or to avoid child's intolerance of bodily
y, with them, thus reassuring humiliations associated with separateness but when this fact
" him against their illusory differentiating oneself clearly can no longer be obscured the
catastrophic effects. as a separate person from child breaks down.
others.
4. As fiuther discrimination 4 Allow mother to over-protect 4 Disturbance in utuo. 4 Low toleration of hutration
incrurres, procoues of 'as if' and to muffle their responses. in child, or in both mother
interplay between mother and child.
and baby protect against too
sharp an experience of
disillusionment. In
Winnicott's terms the motha
provides 'transitional
arpe?icncess. Outside objects
begin to be used as a bridge
between 'mes and 'not-me'.
Normal Abnormal Encapsulated R@ve
R h n q Autism Primary Autism Secondary Autism Secondary Autism
(NJ'A) (A.P.A.) (E.S.A.) (R.S.A.)
5. Immobilization of the limbs 5. Undue passivity in child.
in very early infancy. Can
become E.S.A. or R.S.A.
6. Very high intelligence. 6. A dominating mother and a
paglive father.
7. Hypersensitive responses to 7. A psychotic mother.
sensory stimuli.
8. Low frustration tolerance. 8. Parents who are too 'open'
and do not diciently protect
their own private lile.
g. Depression in the mother g. For various maw* mother
either overt or denied. iacxpcrimcedasan
entangling mother.
10. Mother unsupported by
kther due to indifference,
passivity, absence, illness or
death.
I I. Mother's confidence
undermined by her own
childhood experiences,
intufering relatives or
fiequent changes of habitat.
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lypcs of Autism: Dfmential Features
--
Normal Abnormal Encapsulated Regressive

Primary Autism Primary Au&m Secondary Autism Secondary Autism
(N.P.A.) (A.P.A.) (E.S.A.) (R.S.A.)
NcD.MtolSoli#sinn Prolongation o
f N.P.A. Earb Awest of Dmlopmnt Regression o
f Development
I. A natural first state in which I. Child remains in state of I. This is a protection against I. This is a protection againat
the discreteness of external primary autism due to grossly terror of the 'not-me, not- terror of the 'not-me,
objects is not recognized. inadequate nurturing or known, stranger'. not-known, stranger'.
grossly impaired use of 'Encapsulation' makes for a 'Dispersal' makes for a
nurturing due to inborn character structure which is personality which lacka
defects. Thae can be sulsory unduly rigid. These children structure and is muddled and
or cognitive defects or a are over-dependent on estab- confused.
dficult emotional constitution lished routines which are
or an interweaving of all these experienced as protective
factors. There can be : wrappings which ensure
(a)PmMMnf Prolongation o f bodily survival. This lies at
N.P.A. the root of the autistic child's
Children with grosa attempts to preserve 'same-
environmental lack of ness'. This need also seems
stimulation sink into marasmic to be the baais for neurotic
states and some die. obsessional defences and the
f
(6) TempMary Prolongation o development of rigidly
N.P.A. maintained rituals.
Partial privation due to
environmental or
constitutional defects means
that sudden unbearable
awareness of W i l y
scparatena causer A.P.A. to
become E.S.A. If insecure
development has taken place it
becomes R.S.A.
2. See stages outlined in Chart I. 2. This state is characterized by 2. Processes of illusion of 2. Projective identification
under-differentiationin flowing-over-envelopment becomes excessive to scatter
emotional sphere. &fogged become excessive to become bodily parts into outside
awareness of bodily mcapsdatwn. This aims at : objects. (This scattering is,
separateness, of body image, (a) Shutting out 'not-me' which of course, delusory.) Aim is
of personal identity and is terrifying. to :
aliveness. (6) Covering the 'hole' type of (a) Diminish impact of bodily
depression. separateness.
(c) Holding the precociously (b) Mitigate 'hole' type of
integrated pusonality depression.
together. (c) Feel that bodily bits are
held somewhere. Result is:
(i) Nurturing and
discriminatory reception
of stimuli is hampered by
dispersal of bodily bits.
(ii) Fragmentation of object
and of ego.
(iii) Regression and
deterioration are inevitable
outcome.
Normal A b n d Encaprulatcd Regrcgive
Primary A u b Primary A u b Secondary A u k Secondary Autism
(N.P.A.) (A.P.A.) (E.S.A.) (R.S.A.)
3. Uac of primary autistic objccta 3. Primary autiatic objects such 3. Perseveration of uac of 3. Tranaitional objects are used
give8 place to Uac of as finger or fist continue to be autistic objects which are of compulaively and at an age
transitional objects and used long after time when an abnormal kind, e.g. hard when they are normally
transitional4?xpcrh~. normally given up. or mechanical objecta. given up.
4. Autiam j$wa way to on-goiug 4 In clinical situation may not + In clinical situation separate 4 In clinical situation may
reciprocal rclatio*p& acparate from mother. h m mother without a cling to mother or bring
bachvard glance. tranaitional object with them.
5. Child’a body acema aofl and 5 Child%body acema stiffand 5. Child’sbodymaybc
flaccid. They seem to sink into unrcaponaive. Avert overgrown or ‘gangling’ or
mother’s lap or her ahodder themsclva h m bodily thin and attenuated.
or her aide. contact.
6. Patchy diatinction between 6. Donotseemtodistingttkh 6. Confused diatinction between
live and inanimate ob+. between people and ‘things‘. people and things. Some d
these children talk to their
faeces aa if they are alive
and at timca treat people
aaiftheyarethinga.
7. Thaechildrcnseanto 7. Thm children have made a
operate on a dichotomy confused distinction between
between aublime ‘me’ and ‘nia’-‘-ty’ ‘gd’-‘bad’.
tarifying ‘not-me’; the latter Trouble ia c a d beuuac
being blocked out for most diffucntiationa cannot be
of the time. maintained.Good~get
confused with bad.
8. Little or no fantasy play but 8. Much fantasy play of a con-
a limited play of primitive fused and bizarre kind d d y
imagination around bodily linked to bodily anatomy.
par% hctiona and.p -
9. Children give imprasion of 9. Children give b i i
emptiness and vacancy. impro~sion.
10. Thcse children have become 10. These children seem 'thin-
'thick4imed' (crustaceans) skinned' and have dealt with
to hide their their hyper-sensitivity by
hypa-sulsitivity. becoming confused and
disordered.
'Islands' of thinking. I I. Inhibition of thinking. I I. Confusion of thinking.
May not talk or will talk I 2. Children oilen mute or I 2. Speech confused, fragmented,
'scribble'. echolalic or may have own meagre or meaninglessly
private language which prolix.
reans to have structure and
ryn-
IS. In psychotherapy come IS. In psychotherapy come upan
upon a whole relatively a minutely hgmmted or
undifferentiated object and bizarre object. (Mhmtchiag
a broken object. parta put together in
higgledy-piggledy fashion.)
(Thisis R.S.A.(2).)
14 These children usually avoid 14 Eyes are unfocused. Look
looking at people. through rather than 'at'
people.
15. May appear deaf or blind. 15. May have lack of emation
Nor4 Abnormal Encapsulated R@ve
Primluy A u h Primary Autism Secondary A u b Secondary Autism
(N.P.A.) (A.P.A.) (E.S.A.) (R.S.A.)
16. These children seem to have 16.Thae children seem to have
curled up tightly and shut opened out and scattered
down attention to keep their themselves abroad. They and
hastily assembled penonality, objects in the outside world
intact. They are 'wrapped experienced as separate are
up in themselves' (in their wrapped up in each other.
own body stuff). Some whip
us states of ecstasy in which
they seem to 'hug themselves
with delight'.
Mother and child only I 7. From the child's point of I 7. From the child's point of
differentiated b m each other view the mother seems to view the mother seems to
in isolated patches. have closed down. This may be too a@. This may be due
be due to : to :
(a) The child's frightened (a) The child's unduly invasive
withdrawal from the mother. nature due to excessive gmd
(b) Because the mother is and envy.
rcscrved and withdrawn by (b) Because the mother is con-
nature. fuMd and chaotic.
(c) Because (for a variety of (c) Because the mother is unduly
reasons) she is absent in Mductive and compliant.
body or mind and does not (d) Because she is not a
behave in an alive and continuing figure.
responsive way. (It is usually (a) A combination of the above
a combination of such factors.
features.)
Tom described in this chapter, 18. John and D d are examples 18.These children have achieved
(VII) is an example of A.P.A. of E.S.A. These are some degree of integration.
Thole are flaccid amoeboid 'crustaceans'. These integrations then break
children. down and the personality
seems to split into two parts
(R.S.A.(I) .) There is no
encapsulation. If recovery
does not take place the
personality crumbles and
disintegrates. (R.S.A.(n). )
Ralph to be presented in
Chapter X is an example of
R.S.A.(2). Tobj and Paul to
be presented in Chapter XI1
are examples of R.S.A.(I).
CAapter Eight
CLASSIFICATION AS A BASIS F O R
TREATMENT
VERYoften, each new psychotic child that we see seems to be
unlike any other that we have seen before and to form a diag-
nostic category of his own. This baffling variety of presenting
appearance is because inborn characteristics and impediments
in the child intertwine with those of the parents and with out-
side circumstances which have been catastrophically disturb-
ing. In this chapter, differential diagnosis on the basis of the
type of autism manifested by the child will be suggested as a
means of classification which would avoid what Creak (1967,
p. 369) has termed 'cramping over-simplification'. he com-
mon psychiatric division of psychotic children into those
suffering from Early Infantile Autism and those suffering from
childhood Schizophrenia is too rigid and leaves out many
children who do not fit into the above categories.
The classification to be suggested could only be made after
several weeks of study in a clinical situation by a worker
trained in depth psychology who has had considerable experi-
ence of psychotic children. I t would seem to have the advan-
tage that it provides an integrative scheme which relates the
autism of such conditions as blindness, mental defect and
brain damage to the autism of the Kanner syndrome and
allied disorders, as well as the autism described by Bleuler
(1913) in relation to schizophrenia.
For a therapist, the main value of diagnostic classification is
not to label a child but to constitute a means of assessing treat-
ment possibilities. The main impediment to the treatment of
all psychotic children is the autistic 'barrier' which seems to
exist between them and the outside world. I want to discuss the
nature of this barrier.
102
CLASSIFICATION AS A BASIS FOR T R E A T M E N T
T H E NATUREO F AUTISTICBARRIERS
The first obvious fact is that there is no actual barrier. The
'barrier' would seem to be a way of expressing in a concretized
form the pathological autism of psychotic children which, as
we have seen, is their most outstanding characteristic. On
another level of discourse, Rutter (I966)would seem to be say-
ing this when, in writing of the research study at the Maudsley
Hospital in which he compares a group of psychotic children
with a control group of non-psychotic children, he says:
'Perhaps the most striking difference between the psychotic
group and the control group was the non-distractibility of the
psychotic children, particularly with respect to auditory
stimuli. This again suggests that the chief abnormality in
psychosis may be a deficit or abnormality in the perception
of stimuli.'
In the present book, autism has been defined as a sensation-
dominated state in which perception is elementary, restricted
or grossly abnormal. In its normal aspects, it is a state of
primitive illusion. In its pathological aspects, a vicious circle
develops in which delusions interfere with the perception of
reality and are in t u n intensified by not being modified by
reality. In Abnormal Primary Autism (A.P.A.), the autism
seems to be a direct result of a 'deficit or abnormality in per-
ception' due to the child's sensory 'privation' and lack of
stimulation. However, in Encapsulated Secondary Autism
(E.S.A.) and Regressive Secondary Autism (R.S.A.), it seems
to be the result of not paying attention or of an abnormal
direction of attention. This is not quite the same as a defect
in perception, although it amounts to the same thing in the
end.
Nurturing, and receptivity to and ability to use nurturing,
seem to be the means whereby the normal child builds a work-
ing construct of commonly agreed reality which enables him
to use the resources of the outside world and make contact
with the people in it. The vicious autistic circle which excludes
nurturing gives rise to the sense of there being a 'barrier'. The
E.S.A. child is locked in what seems to be an immutable
autistic state with little inner world. A restricted type of
imagination plays around bodily processes, but this is not
fantasy in the usual sense of the word. Klein's term unconsciou
pAontasy is as good as any other for the inchoate elemental pro-
cesses associated with what have been termed innate forms.
Configurations of these would seem to compose the archetypes
of Jung's formulations.
As we have seen, clinical material suggests that the infant's
primary illusion is that he and the mother are a continuum of
body stuff: Over-harsh and too-abrupt awareness of bodily
separateness from her being experienced by the child as a
break in bodily continuity. Convulsions of panic and rage
mean that this is experienced as body stuff coming to an end in
a disastrously explosive way. Such material as that of David
indicates that the attempt to smear around the disconnection,
to obliterate it with obfuscating body stuff, results in the delu-
sion of an impenetrable barrier against stimulation. As we
have seen, this can be to the point of blotting out external
objects. Psycho-analysis has coined the term negative hallucina-
tion to describe this situation. In everyday terms, this negation
of the outside world seems to be a persisting umbrage arising
from intense aversion to the 'not-me' which has been catas-
trophically upsetting. The child opts out and shuts down. This
leads to the sense of a barrier being between the child and other
people.
I t has been suggested that the child is not aware of the
barrier and that it is a construct of the observer (Anthony
1958).In my experience, as David's material exemplifies, the
child is aware of the barrier. At certain times he shows that he
is aware that his autistic activities which have aimed at self-
sufficiency block his capacity for responding as a real person to
real people and objects. This is understandable when the
whole system of pathological delusion is seen as a reaction to a
sense of catastrophic breakdown of bodily flow, and a sudden
104
CLASSIFICATION AS A BASIS FOR TREATMENT
and alarming sense of separatedness when reality presses too
hard and too sharply.
This is where normal and pathological autism are different.
Normal autistic processes in infancy seem to be in the nature of
flowing-over and cnv~lopmt,leading to at-om-m.rs with the
mother. In pathological states of over-reaction these seem to
become eruptive extrusion and intrusion, leading to encap-
sulation. These pathological processes aim at at-one-nws with
the mother but they result in separatsd~ss(alienation). There
has been sharp and painful awareness of reality, but it is
blocked out because it is terrifling.
This alienation becomes more pronounced as the years go
by. Whenever situations arise which are analogoua to the
original trauma, the 'hole' is re-experienced. This means that
the barrier is reinforced. The child's negativism not only
remains unmodified but is strengthened.
As we saw in David's material, as well as being a barrier
against stimulation from without, the encapsulation serves to
protect against violent feelings h m within, for lack of having
a sufficient sense of a nurturing object who can do this. I t
serves to keep under rigid control the violence which threatens
such children's insecurely integrated structure.
As we have seen, most psychotic children are too frightened
to look and see, to hear and listen. When, as the result of treat-
ment, their terror-struck negativism is becoming more expres-
sible, the E.S.A. children may actually put their hands over
their eyes, or cover their ears (one boy did this by folding the
top part of his ear over to block the ear cavity). Thus, the in-
hibition of attention is expressed as making a palpable barrier.
(At this stage, one would infer that there is some sense of
bodily separateness.) This behaviour on the part of 'recover-
ing' E.S.A. children suggests that the autistic barrier, in one of
its aspects, is a pathological over-development of the natural
tendency to use one part of the body to protect another, like
hands over ears or eyelids over eyes. A similar, though perhaps
more primitive, use of this was illustrated by David's material
105
(Chapter Three) in which body substances were felt to flow
around himself or other objects to keep out death-dealing
things. It is also to protect the sublimely 'nice' object formed
from blissful nurturing experiences which seem to cocoon the
infant with a psychological 'skin'.
Clinical material indicates that solely autistic ways of coping
with 'nasty-not-me' things are not satisfactory. I t seems likely
that they can be used on a temporary basis until the reciprocal
to-and-fro between mother and infant modifies the te-g
'not-me' so that it becomes tolerable, but as a long-term
measure they are not satisfactory. As David's material illus-
trated, autistic methods of healing and protection interpose a
rigid and difficult-to-mode barrier between the child and
the outside world.
R.S.A. children with a confused experience of their own
separateness seem to be aware of a barrier between themselves
and others. One such child, Ralph, who will be described
later, was continually struggling out of tattered 'grave' clothes
from which he knew he was separated and alive. (These
entanglements were interpreted to him in term of projective
identification with an envied mother who had thus become
fragmented and reduced to rags and tatters, and in whom he
felt he was buried alive.) At the height of their withdrawal,
E.S.A. children are not likely to be aware of the barrier
because of their massive retreat from awareness of separate-
ness. However, when the trauma is re-experienced, or as treat-
ment progresses, or spontaneous improvement takes place,
they seem to be aware of the barrier. In the course of improve-
ment, John (of Chapter Two), brought material about a
heavy-laden 'wet-blanket' mother who wrapped herself
around baby John as if she were a dirty nappy, that is, as an
autistic object. He tried to 'swish' this autistic mother away
from before his eyes by using his hands as if they were a pair of
windscreen wipers. This was a depressed mother experienced
in the primitive way of being f d of accumulations of wet body
stuff such as urine, faeces and tears, and whom he felt he made
so utterly part of himself that he was called upon to perform
the impossible task of cleaning her up. Loaded with projections
of body stuff which was black with rage and would not come
clean, he felt his perceptions of the outside world were blocked.
Psychotherapy aimed at showing him that there was a way
out of this dilemma of bodily-experienced black despair. As
his fright about bodily separateness from his mother was
relived and worked over in the treatment situation, so that
his need to react to her as a part of his body was modified, he
could begin to relate to her as a mother having a refkshing and
cleansing to-and-fro with the father. He was no longer stuck
with his mother as an inanimate extension of himself. Thus,
being relieved of the 'wet-blanket' mother, he could begin to
use the transforming functionsof the parent's intercourse with
each other, and symbolicactivitiescould be set in train.
Apart from the frightened negativism which results in in-
hibition and distortion of perception and withdrawal from
nurturing, there is another source of the barrier. This is non-
communication. Lack of communication (either non-verbal
or otherwise) is experienced as a barrier and increases autistic
imprisonment. There may be times when the child tries to get
in touch with someone, and someone tries to get in touch with
him. For various reasons, they cannot manage it. In this case,
the barrier is a nonevent, a non-communication, the lack
being experienced as an impediment (E.S.A.), or as a baffle-
ment (R.S.A.).
The foregoing examples illustrate that the 'barrier' can
take several forms and that, although it is a delusion, it exerts
a powerful influence on the child and his functioning. As
stated previously, it would seem to be a normal process which
has become over-developed. A relatively normal person told
me that the only way in which she could prevent herself from
fainting at the sight of blood was 'to bring the black shutter
down over my eyes'. There was no actual black shutter, it was
a i f the blackshutter came down.
In ordinary life we may experience this delusion of a barrier
when talking to a foreigner whose language we do not know.
We must all have had the experience that we find ourselves
shouting at him in the delusory notion that if we shout loud
enough the barrier that seems to be between us and him will be
scaled or broken down. This is natural enough, for we feel that
if we can get him to pay attention then he must understand
what we say. Of course, this is not so, and after some thought
we may try to evolve a sign language which enables us to have
a very simple type of communication with him. This is a
reasonably effective short-term measure. However, the long-
term approach of learning the foreigner's language and some-
thing about his ways and customs is the most effective one. To
a limited degree, this analogy can be applied to psychotic
children; we need to learn their 'language' and enter into their
world, in so far as this is possible, if we are to communicate
with them. In Bion's terms we need to have a capacity for
'reverie'. More will be said about this in the chapter on psycho-
therapy.
TREATMENT PROSPECTS
Abnormal Primary A u h (A.P.A.)
The institution infants who manifest A.P.A. are likely to
have suffered so much early damage due to their 'privation'
that it has become almost constitutional. I t is to be expected
that the emotional life of these children will be little differen-
tiated. It is difficult to do much to help them, and indeed, as
we have seen from Spitz's children, gross early 'privation' and
lack of stimulus often leads to death before the age of two years.
Even their physical developmentseemsto have been damaged.
Genevieve Appell, in her film 'Monique', has demonstrated
techniques which aim at giving such children the stimulation
and sensory satisfactions they have missed, in the hope that
they can make use of them at this later stage. For this type of
treatment it seems to be important to treat the child as young
as possible, and the outcome then seems to depend on the
child's constitutionalendowment and degree of privation.
Other family children who, for various reasons, lack stimu-
lation (e.g. being left too much in prams and playpens), when
combined with other privations may show varying degrees of
A.P.A. An example of this was an illegitimate boy who was
breast fed by his young mother for two weeks, after which time
she had to go into hospital for one month. She left the baby
with her own mother during this time. On her return from
hospital the grandmother continued to look after the baby
whilst the young mother went out to work. He was a very good
baby and the maternal grandmother tended to leave him in his
pram a great deal. At eighteen months, although well co-
ordinated in his body, he was showing unmistakable signs of
withdrawal. His eyes lacked sparkle and did not seem to be
looking at objects in the outside world, he was apathetic in his
responses and was difficult about taking his food.
After a month of being cared for by his mother, who gave up
work to do this, he became more responsive. I t seems hopeful
that, given the stimulating presence of his mother who talks
to him and plays with him, he will become normally respon-
sive. This child has been retrieved because he was seen by an
experienced paediatrician who knew the danger signals and
who could help the mother to begin to meet the psychological
needs of her infant.
Some, but not all, mentally subnormal children tend to
remain in a state of primary autism for an unduly long time
because they are hampered from using the stimulation which
is available. If, in addition, they are left alone a good deal and
unduly left to their own devices, this increases their autism.
The child's own nature is also important. For example, the
mongo1 child, who is usually affectionate and responsive,
rarely shows autistic features. These children, like blind and
deaf children, need specialized educational techniques which
are not part of the theme ofthis book. The difficultyin assessing
treatment possibilities is to know whether the autism arises
from an inherent degree of mental retardation or whether
there is reasonably good intellectual potential. Again, this
cannot be determined with computer-like accuracy but
experienced workers can often get a 'feel' about a child's
capacities even though they may not be being used.
Encapsulated Secondary A u h (E.S.A.)

Some children who have continued in the state of primary
autism for an unduly long time may have a traumatic experi-
ence of bodily separateness because the abnormal prolonga-
tion of primary autism has prevented them from developing
much inner experience. These children then come into the
E.S.A. category.
Other children may remain in a state ofAbnormal Primary
Autism (A.P.A.) for an unduly long time because their every
need is met too quickly. They are usually reported to have been
'good babies' and, as they develop, they are unduly teachable.
They seem to have by-passed all awareness of frustration by
being compliant and accommodating, just as the mother (or
both parents) has been towards them. When awareness of
frustration can no longer be avoided it is likely to be traumatic
because of the lack of inner readiness to cope with it. They
often have a history of normal development but this seems to
have been mostly on the basis of compliance-of moulding
and being moulded. These children can become E.S.A. or
R.S.A. children according to how they deal with the trauma
of separateness. If development is arrested and encapsulation
processes are dominant they become E.S.A. children.
Pefer was such a child. When I first saw him he had a trim,
well coordinated body and an intelligent face, but he avoided
looking at people. Very often he seemed apathetic and muted,
but sometimes he would jump up and down and laugh ex-
citedly. This seemed to be in order to avoid any feeling of frus-
tration and separateness. When threatened with awareness of
separatenesshe reinstated the charmed circle of 'nice-me' and
no 'nasty-not-me' by jumping up and down in an ecstatic way,
or running round and round in circles, or running up to an
adult and putting his arms around them. (This was not in a
burrowing way with his head butting into the grown up's
stomach, but with an encircling movement of his arms.) Such
actions seemed to obliterate any sense of alarming separate-
ness. He seemed to use ecstatic perseveration at some activity
(for example, play with sand) to shut out awareness of any-
thing else. The material with which he played seemed to
become a combination of his own body which shut out aware-
ness of anything else.
Here is an account of my first observation with him.
Peter. A puzzling little boy. Recited many nursery

rhymes, surprising number for his age and the parents did
not seem to realize this was surprising. Did it in a somewhat
parroting fashion.
In the therapy room he stuffed an elephant, cow, sheep
and lamb into a wooden shed as ifhe did not want to look at
them. He then dug with the spade in the sand in a desultory
fashion and I found my thoughts wandering.
The dramatic moment came at the end when he wanted
to take the spade. I stopped him and said 'no spade', at
which he screamed and lay on the floor kicking with rage.
He kept going back to the spade. I was firm and he kept
getting angry but slightly less and less so. Finally, he went
to the sand tray and picked up handfuls and then let it
trickle off as if this comforted him and as if he was trying to
take away the sensation on his hand instead. At last he was
ready to go without the spade.
The E.S.A. children have had to face traumatic 'goneness'

in the mouth whilst functioning in the omnipotent terms of
innate forms with their stereotyped and automatic responses.
Their omnipotencehas been disturbed before they had become
able to use ordinary nurturing experiences from a mother who
was recognized as separate and alive. As a protective measure
they seem to have curled themselves up tightly and shut out
the outside world. This inhibition or restriction of attention
results in the awest of emotional and intellectualdevelopment,
but physical development separates off and proceeds auto-
nomously. Study of E.S.A. children promises to throw light on
the early stages of emotional and intellectual development.
With the R.S.A. children the picture is more confused and
complicated so they do not give us such a precise access to
early developmentalstages.
Th Tongue
Work with E.S.A. children seems to suggest that the tongue
plays an iniportant part in early infantile development. This
is a bodily organ which has been little discussed in psycho-
analytic literature. In an interesting paper, Augusta Bonnard
(1960) described the marked improvement made by tongue-
swallowing children when the significanceof their tongues was
discussed with them. They made great spurts in their intellec-
tual and emotional development. She reminds us that the
tongue is our first 'major scanner' (Bonnard 1960, p. 304). It
seems feasible that the feeling of the tongue in the mouth ('the
primal cavity', as Spitz terms it) brings the child his first
experience of space. At this stage, the tongue would be the
infant's whole experience of 'being' and would not be experi-
enced as apart of the body. I t seems that the early oral trauma
may have been associated with the feeling of the tongue sud-
denly being 'in space' without the lulling continuation of the
mother's body afforded by the teat. Many E.S.A. children,
when they begin to draw, are preoccupied with problems of
perspective and the drawing of three-dimensional objects in
space at a time when this is not usual, or to a degree that
amounts to an obsession. Awareness ofseparateness is insepar-
able from awareness of space and brings with it awareness of
outsides and insides. It seems feasible that insi& the mouth is
the primary experience of inside the body. Until awareness of
'insides' has been achieved, inner life is not possible. E.S.A.
children have blotted out awareness of separateness and thus
of space and of inside and outside, so they have little or no
CLASSIFICATION AS A BASIS FOR T R E A T M E N T
inner life-which accounts for the impression they give of
emptiness and vacancy.
Rw
They are also very inhibited in the expression of anger. (It is
when they are recovering that temper tantrums are a feature
of their behaviour.) This seems to be because they are afraid
of the explosive rage which threatens to blow them into pieces.
As they recover, temper tantrums become a feature of their
behaviour. Rimland states that they occurred in an autistic
child treated by the drug Deanol, and it has been my experi-
ence in psychotherapy. Prior to this progress, the rigid encap-
sulation has kept the convulsive rage within rigid bounds. Fits
arc a feature of some E.S.A. children, which arouses the
speculation that, in some of the children at least, these may be
attempts to find release for the pent-up rage. Before he had
tantrums, John's parents (Chapter One) described how he
went rigid 'as ifhe were trying to push out somethingvery bad'.
They were afraid he was going to start having fits. Clinical
material indicates that this 'very bad something' seems to
threaten survival.
In a state of secondary autism, the patient seems to feel that

the flow of bodily substances into and around the therapist
(mother) makes her exist. Bodily substances are felt to fill up,
deprival to deflate. Bodily movements are felt to have a
similar power of life and death. Sucking means that the breast
exists, not-sucking means that it does not. Looking brings the
object into existence, not-looking annihilatesit. Thus, the very
existence of the therapist (mother) seems to depend upon the
child. He feels he has to keep the world turning. Thus, in a
stage of 'pre-ruth' (Winnicott's term), the child is over-
burdened with responsibilities concerning the survival of
himself and others, far beyond human bearing. A further
intedcation comes from the fact that in these states, that
which has to be done is magnified, and yet capacities are
stultified. Being 'puffed up with his own importance' is not
really a comfortable state to be in although sometimes it seems
to be so.
A psychotic child in this state sucks his tongue or makes
bubbles or bubbling noises in his mouth in order to feel that he
has the vital bit of the mother which comforts and fulfils his
mouth. This keeps at bay the dread that vital supplies will
come to an end in an untimely, treacherous and madly tan-
talizing way. If he could speak about his state, the psychotic
child might cry, 'My God, I am undone'. This 'undoing' is
avoided at all costs by the autistic reactions being described.
In this state the child may even 'talk' in a garrulous, non-
communicating way to feel that he is 'creating' what he feels to
be the completion of his mouth, thus maintaining his false
sense of self-sufficiency and domination. I t is clear that this is
not true creativity, for it is unrestrained by reality limits. The
mother (the outside world) is felt to be his 'creature' to give
him exactly what he wants.
Bisexuality
When E.S.A. children are seen in treatment they often play
with the sand, spooning it in a muted apathetic fashion. Work
with 'recovering' E.S.A. children gives us clues as to what may
be going on during this desultory period. One child told me
that he had been 'making shapes' in his mouth with his spit,
just as he made shapes in his bottom with his 'poohs'. He said
these shapes were 'monsters'. He drew one of these monsters
which in the second picture bifurcated into male and female
monsters. This differentiation of body stuff in terms of his
bisexuality seemed to be experienced in terms of thrustingness
and receptivity. David's material illustrated that, in order to
escape from the effects of his enclosing activities with the soft
mother, he used his male thrustingness to bring about the
entire encapsulation of himself within the body of the hard
father. (It will be remembered that in these states parts are
felt to be the wholes.)
This concentration of his whole attention upon the male
aspects of himself and his nurturing meant that the female
contribution was blotted out. This belittling by the E.S.A.
child of the receptive female contribution to his welfare may
be one reason why, when a superficial view is taken, the
mother is felt to be solely responsible for her unhappy child's
condition. Since she often undervalues her contribution, this
plays into the child's psychopathology, as also a false assess-
ment ofits cause.
Clinical material implies that all this happened in relation
to the mouth (the primary receptor) and his tongue (the
primary thruster). Later notions of male and female, mother
and father, seem to develop from this primal basis. So long as
development proceeds in terms of an exclusive response to one
or other aspect of himself or to those aspects of the outside
world conceived in solely autistic terms, it will be insecure. He
needs to bring both aspects of himself together and to feel that
both parents come together in a constructive and creative
union.
As we have seen, premature mouth awareness of uncom-
pleted gestalts causes the child to startle with panic and rage.
In early infancy, the sense of an uncompleted circle causes
developmental patterns to occur too soon and to be super-
imposed upon each other. The mouth seems to become eroti-
cized, leading to later pseudo-phallic development. The fact
that the nursing pattern of nipple-in-mouth is similar to the
sexual one of penis-in-vagina and the anal one of faecal stool
in anus, may have somethingto do with this.
In treatment, the therapist gets the impression that many
zones have been stimulated at once instead of developing their
primacies in an ordered fashion. Due to the upsetting loss of
the illusion of at-one-ness with the mother, the nursing situa-
tion seems to be divided in terms of nice-nasty, soft-hard,
receptivity-pushingness, 'femaley-'male'. 'Bisexuality' seems
to develop too soon and in a peculiar way. The children seems
to be precipitated into a rudimentary 'oedipus complex', out
of phase, and shot through with polymorphously perverse
elements. Let me try to describe this bizarre phenomenon.
The mouth seems to become sexualized, as well as other
parts of the body experienced as the mouth: for example, the
anus and the hands. In delusion, the child encloses bodily
parts of the mother as an inanimate and phallic part of him-
self (for example, the nipple or her hand or her hair or her
beads, etc.) (Maybe she does this to him.) His own bodily parts
also become sexualized, his fingers, his hair or his faecal stools.
His mother is used as a tool, a manipulable extension of his
own organs, a sort of phallic flower in his button-hole to make
him feel 'special' and under 'special protection'. (He then feels
that he has to be the phallus for her.) This phallic, male bit is at
first felt to be part of the mother but, at a certain stage, as
separateness is experienced, a malevolent 'father' seems to
come upon the scene to vie with and to threaten the child for
his possessive enclosing activities in relation to the mother.
Thisis a delusion formed from his own bisexuality which bears
no relationship to the real father, so that the 'oedipus complex'
is not the same as that described in classical Freudian liter-
ature. It is pathological, and of an 'as if' variety. One recover-
ing autistic child, who had reached the stage of being able to
dream, described this oral-cum-sexual appearance of a phallic
father by a dream about a bowl of creamy milk in which there
suddenly appeared a tuft of male pubic hair, at the sight of
which he felt sick and terrified. This delusory 'father' can
affect the child's relationship to the real father and, until this
phantasm has been modified, the child's relationship to the
real father is likely to be disturbed.
The psychotic child also seems to feel that he has looked at
something which should not be seen. In the contradictoryway
which is a feature of psychotic states, in a state of 'not-knowing'
he a h feels that he 'knows' too much. In so far as it is poaible
to express this bizarre, non-verbal phenomenon in words, it is
presented as an uncontrolled and violent coming-together of
destructively sexual 'parents' who threaten the child with a
fate that is worse than death. This phenomenon seems to spring
autistically from the child's own impulse-ridden, precociously
aroused bisexuality, there having been a too-sudden bifurca-
tion from the stage of primal unity with the mother.
In pathological states, the thrustingness seems to get out of
control to become hyperactivity or the receptiveness becomes
over-developed and turns into extreme passivity. The seem-
ingly paralysed and frozen children appear to rid themselves of
thrustingness by provoking it in the outside world or seeing it
as coming from there. They thus feel at the mercy of prodding
and poking which threatens their over-passive receptivity.
This keeps them in a terrified state of inanition and inhibition
which renders them unduly vulnerable and malleable.
Since the whole experience is associated with intense dis-
comfort and frustration, the mouth and nipple do not seem to
come together in a good intercourse. Failing a primal experi-
ence of good linking, the links between the various parts of the
personality are insecure. To counter this the E.S.A. child
becomes encapsulated (emotionally sealed off), but physical
development separates off and proceeds autonomously. Thus,
the physical development of the E.S.A. child is usually satis-
factory. In the R.S.A. child, for lack of the containment
arising from a good primary experience of linking, the in-
securely held together psychological-cum-physiologicalparts
are dispersed into other objects. H is physical development is
much less well co-ordinated and satisfactory than the E.S.A.
child's. I t will be clear that both types of psychotic child need
firm holding to reassure them against the risk of falling apart.
Envelopment and Encaapsulation
The development of the E.S.A. child seems to have been
arrested at the stage when moulding and flowing around out-
side objects in terms of innate forms was at its height. In
this state, awareness of separateness would seem likely to be
transitory and fleeting, to be lost as soon as the moulding
and flowing-aroundactivitiesbrought the feeling of unity with
the nurturing object.
The E.S.A. child mainly uses global encapsulating pro-
cesses, for he has dealt with the mouth trauma of premature
bodily separatenessby pulling out of the nursing situation and
closing down. He seems to lie dormant until developmental
conditions are more propitious. Beata Rank used to say that
within the autistic shell there was a sleeping prince or princess
waiting to grow up. The danger is that the retreat will become
habitual, and response to outside stimulation be so reduced
that outgoing responsiveness becomes impossible. However,
the more we understand the factors that have gone into this
retreat, the more we may be able to help him. The trouble is
that the child lives in a mad world, and attempts to describe it
seem outrageously mad and extraordinary. The foregoing
description illustrates this very well.
Treatment
Prospects of some degree of stable improvement in the
E.S.A. child seem to depend on constitutional strengths in the
child, his intelligence-potential, the family setting, whether
skilled support is available for the family, and the therapist's
insight into autistic processes. Th& insight helps the therapist
to bear the period when he is shut out and nothing seems to
happen. When the child begins to respond to the therapist, it
plays a major r61e in enabling the child to use these processes
less excessively, so that they may form a 'membrane' which is
discriminately receptive as well as protective. His need for
armouring himself against the 'nasty-not-me' outside world
becomes modified as the gap between expectation and reality
is better tolerated and transitional experiences, such as dreams
and fantasy-play develop as safety valves for the expression of
the panic, rage, despair and helplessness resulting fmm this
gap*
If their autistic encapsulation can be modified, it would
seam to be more possible to help the E.S.A. children than many
of the R.S.A. children. The R.S.A. dispersal techniques,
although more successful as a short-term, measure, in that
development of a confused and 'patchy' kind takes place, are
not successful as a long-term solution, and indeed are detri-
mental in that fragmentation and dispersal impede ultimate
integration and spontaneous recovery, or possible psycho-
therapy. The E.S.A. method of dealing with the fear of falling
apart has kept the primitive personality more intact. In
Peter's material presented earlier in this chapter, the encap-
sulation was expressed in his pushing the animals into the
wooden shed. They were not scattered as an R.S.A. child
would tend to do.
Regressive Secondmy Autism
The term regression is used here in the sense of going back to
an earlier state of emotional development. Integration is
thought of as a progression, disintegration as a regression to a
near-state of unintegration. In normal development a certain
measure of disintegration can be a 'reculer pour mieux sauter'
but in R.S.A., due to the codksion and fragmentation associ-
ated with the disintegration, this is not so. Indeed, in R.S.A. (2)
children, even integration becomes a regressive step for, after a
time, the physical-cum-psychological parts are brought to-
gether in such a fiagmented and bizarre way that the patho-
logical state becomes progressively worse unless therapautic
intervention comes early. (In therapy we come upon what
Bion (1962) has termed a 'bizarre object'.)
The following is an observation session with such a child,
including the gifted teacher's report.
lkapist's Obsmatr'on
Susan came into the room with a piece of cardboard in
one hand and a small plastic saucer in the other. These two
things were never allowed to come into contact with each
other; they were kept quite definitely apart. She flicked
these in front of her eyes so that her perception of outside
objects must have been of a jerky, spasmodic kind. Her
speech was similarlyjerky, in separate slabs of communica-
tion with gaps in between. For example, she said, 'Susan
.. ..
flicks. mother not go away. Daddy here.' (Her father
was a serving soldier home 'on leave'.)
She spread the toys all over the table in a haphazard
fashion and then, in response to my going to the door to
close it, she anxiously gathered them together into bags.
There was no attempt to sort them. The zoo animals were
mixed with the farm animals and with the wooden houses.
TeachmasReport
Susan's temper outbursts have altered over the last two
years. Previously she used to attack her own face, making
holes at the base ofher ear lobes, which she would not allow
to heal over. Then she 'progressed' to making holes in one or
both cheeks which she would make bleed profusely, saying,
'Look! Look! Look!' all the while. These holes used to
worry her very much and very gradually she has stopped
doing this.
When a tantrum is nearly over the screams have a
theatrical nature as if she is listening to them, and some-
times she makes them have less and less intensity until they
fade away completely, upon which she opens her mouth
wide and says, 'screams all gone'.
When Susan comes into physical contact with somebody
or something, and when this contact was unsolicited by her,
she feels in some way violated until she has gone through
the symbolic gestures of taking back from the other person
or thing the parts of their anatomy which came into contact
with her and meticulously replacing them. This process is so
complicated that it really defies description. For example,
during a temper tantrum, I once had to forcibly pull her
across the floor. When she had calmed down she carefully
retraced her path picking up and replacing the bits of her
rear which she imagined were still on the floor. Then she
came to me, carefidly opening my hand to take from my
fingers and replace all the pieces of her body which I had
touched."
The R.S.A. child seems to protect himselfagainst the 'nasty-
not-me' outside world which is felt to tease and let him down,
by diminishing and diluting its impact. He does this by the
delusion of scattering bits of his body widely into it. These bits
are often fragmented in an attempt to decrease still further the
painful impact of bodily separateness. However, on the basis
of being spread thinly to diminish the impact of the trauma of
separateness, some shaky development takes place and fan-
tasy-play and speech develop. These are confused and often
fragmented, full of non sequiturs. The fact that the parts of the
personality, which in delusion are dispersed, are little differen-
tiated b m bodily parts means that the bodily co-ordination
of the R.S.A. (2) child is sometimes poor. Also, this disperal of
bodily-cum-psychological parts is often expressed in hyper-
activity or bizarre body movements. These phases of hyper-
activity, in which bits of their body are felt to be dispersed, are
often followed by frozen immobility. Mme Sechahaye des-
cribes a very regressed adult patient who said, 'I did not want
to move because, if I did, everything changed around me and
upset me so horribly, so I remained still to hold on to a sense of
permanence.'
I t seems likely that, for this patient, movement in the
outside world meant disturbance of her scattered bodily
parts.
The prognosis for R.S.A. children seems to depend upon

the degree of fragmentation associated with their dispersal
techniques, the degree of their confusion, the type of help
* I wish to thank Miss Janet Pratt for permission to quote thia report.
Thin war an R.S.A.(2) child.
available for the parents to facilitate and bear the disentang-
ling of themselves from their child, the constitutional strength
of the child, the degree of intelligence-potential, and the
capacity of the therapist to have insight into the autistic pro-
cesses used by the child.
With the R.S.A. children treatment begins at once but is
hampered by the confusion and muddle provoked in the thera-
pist, and by the 'mix-up' which tends to develop between
child and therapist. The therapist has to experience the
muddle but at the same time have sufficient detachment to
retain a clear head. Confusion can be a powerful weapon in
the service of envy, and may be the source of the child's un-
doing. A common delusion of the R.S.A. children, who have
more sense of separateness than the E.S.A. children, is that
bits of body stuff are put inside the envied person to impede
their creativity-a kind of spanner in the works. A primitive
notion of the parents' creative linking with each other is a
source of great envy, and there are delusions of blocking it with
body stuff. Thus, these children's confusional states tend to be
perpetuated.
Another feature which hampers therapy with the R.S.A.
children is that they are more intricate, devious and compli-
cated than the E.S.A. children. They have developed in a
confused way from an insecure basis, and regressive processes
become more and more established unless some outside inter-
vention comes to stop the inevitable deterioration. In psycho-
therapy, we come upon a minutely fragmented, denuded or
bizarre object, and healing is a time-consuming and perhaps
impossible process. The more global E.S.A. children have a
whole exciting omnipotent and relatively undifferentiated
object and a broken object.
The indiscriminate lumping together of all types of child
psychosis has caused the erroneous view to be taken that the
E.S.A. and R.S.A. children have inevitably had cold mothers
who deprived them of sensory satisfactions. This has resulted
in therapy which has aimed at providing bodily contact and
sensory satisfaction. As we have seen, E.S.A. and R.S.A.
usually have different precipitating causes from A.P.A. To try
to give E.S.A. children sensory satisfaction by caressing them
is often frightening, for some of them recoil from bodily con-
tact, as witness Susan. I have seen a psychotic child become
catatonic as the result of a well-meant attempt to cuddle and
comfort him. I have not found that the R.S.A. and E.S.A.
children who have responded to treatment have needed much
modification of the psychotherapeutic technique used for
neurotic children, although treatment has made great
demandson the therapist.
An understanding of the autistic processes of encapsulation
and pathological projective identification (whatever terms we
use for them) is essential in the treatment of E.S.A. and R.S.A.
types of child psychosis. Difficulties in understanding and
accepting the validity of these autistic processes comes from a
lack of understanding of their nature (aswell as from semantic
difficulties). In their pathological manifestations, that is, when
they are used excessively, they are delusory 'as if' processes
leading to the 'false self (Winnicott) and the 'as if" person-
ality (Deutsch). In the course of improvement due to psycho-
therapy, 'acting out' is often used as a means of expressing
these pre-verbal elemental dramas which have not been
brought within the orbit of parental and cultural nurturing,
which mediates generally agreed reality.
In their normal use, at a certain elementary stage of emo-
tional growth, these autistic processes of illusion are the means
whereby the infant gets in touch with the outside world and is
temporarily protected from too violent a contact with its lack
of fit to inbuilt expectations. Most neurotics, and possibly nor-
mal people, seem to have a pocket of pathological autism. In
understanding psychotic children we can use this autistic
pocket to help us to enter the fringes of the unreal world of
these helpless children.
EARLY INFANTILE AUTISM AND
CHILDHOOD SCHIZOPHRENIA
AS SPECIFIC SYNDROMES
THEvarious kinds of pathological autism have been differen-
tiated and compared by means of the charts at the end of
Chapter Six. In the present state of our knowledge of child
psychosis, differential diagnosis in terms of the type of autism
is a useful rough and ready way of classifling psychotic dis-
orders of childhood on the basis of a critical feature of its
psycho-dynamics. This method of classification by types of
autism prevents our lumping together all the heterogeneous
cases of child psychosis into a 'hotch-potch' (Kanner 1958,
p. 142), and yet it also 'leaves the door open revealing our
perplexity and confusion' (Creak 1967, p. 368). However, as
more psychotic children are being seen and described, two
syndromes seem to be emerging which can be distinguished
with some exactitude. These are Early Infantile Autism and
Childhood Schizophrenia. (This still leaves many psychotic
children who fall outside these two categories.) In terms of the
type of autism, Early Infantile Autism comes into the category of
Encapsulated Secondary Autism (E.S.A.) and Childhood
Schizophrenia into the category of Regressive Secondary
Autism (R.S.A.).
The syndrome of Early Infantile Autism was first described by
Kanner in 194.3, at which time it was important to distinguish
it from mental sub-normality. Recently, on the basis of
external characteristics, Rimland has usefully distinguished it
from Childhood Schizophrenia and has described it in a more
precise way than did Kanner (Rimland 1964, pages 67-76).
At the end of this chapter, on Chart 111,differential features of
124
SPECIFIC SYNDROMES
EarZy InfanhanhIs
Autism and Childhood Schizophrda are compared
in terms behaviour and psycho-dynamics.
Meltzer (1963) has formulated differential distinctions in
terms of psycho-dynamics. Of ChildhoodSchkophrenia he writes :
This is a rare clinical syndrome found mainly in children
of schizophrenia-tainted families, generally insidious in
onset following weaning, the birth of a sibling, maternal
separation or trauma, in children of marked schizoid
temperament-i.e. a weak capacity for love, extremely
severe destructive enviousness and intolerance to psychic
pain. The clinical picture is preponderantly hebephrenic
partly due to the unconscious adjustment of the environ-
ment to the illness which masks the more paranoid and
catatonic features. Thege children are ineducable, may
seem mentally defective and present an as yet virtually
untouched research problem in psychotherapeutics.
As well as being an example of Regressive Autism, Ralph (to
be presented in Chapter Ten) would seem to be an example of
Childhood SchizopArenia. Limited but useful help was given to
him, and the parents had skilled help in coming to terms with
any unrealistic hopes they may have had concerning the out-
come of treatment.
Of Ewly I n f d I s Autism (Wing 1966, has suggested re-
placing Kanner's term with Ear4 Childhood Autism) Meltzer
writes:
A far more frequent type of child, often misdiagnosed as
deaf, blind or mentally defective. Usually h m intelligent
and educated families, but born in a period of parental
separation or turmoil, particularly characterizedby depres-
sion in the mother. As they are children of sensuous and
affectionate disposition and often good feeders, disturbance
is seldom noted until after weaning, and especially
when speech development fails to progress. Their bizarre
qualities are often accentuated by the birth of a sibling
and maternalseparation.
He also says that they are children of an 'intensely jealous

possessive disposition'.
I would substantially agree with the above description of
childhood autism but would not use the term as widely as
Meltzer does. Some of the children he classes as Early Infant&
Autism I would put into the category of E.S.A., in order to
reserve the term Early Childhood Autism (as Rimland does) for a
more specific symptom-combinationwhich occurs much more
rarely than Meltzer suggestsin the above passage.
THESYMPTOM COMBINATION OF
EARLYCHILDHOOD AUTISM
I would see early childhood autism as being invariably
associated with the genetic endowment of good or high intelli-
gence potential. Of course, this cannot be assessed when the
child is first seen, for such children are untestable. However,
useful indications of this would be if one or both parents were
of good or high intelligence, or came from families in which
certain members had had high intelligence. Of course, this is
not a certain indication: a highly intelligent child can arise as
a 'sport' in a family of more normal intelligence. A child of low
or average intelligence can be born to highly intelligent
parents. However, if the child can be seen for an assessment
period of several months, an experienced therapist or teacher
can often get the 'feel' that she is dealing with an intelligent
child, even though he is withdrawn and mute. Of course, this
can only be a 'hunch', which means that a diagnosis cannot be
made with computer-like accuracy. The potentiality for good
or high intelligence is important in terms of prognosis, for it is a
factor which aids psychotherapy provided the child is under
the age of five or six years.
Other features associated with the syndrome are that there
is usually no history of maternal separation, the child's with-
SPECIFIC SYNDROMES
drawal dating from early in life and not seeming to be related
to any particular event, although there is sometimes inten-
sification of the withdrawal on the birth of a sibling. There is
often an early history of screaming and temper tantrums as
distinct from the 'unusually good baby' type of history of the
schizophrenic child. (These early protests are encouraging
prognostic indications.) Such children have no obvious fan-
tasy life, are often mute or have very little speech. If they have
speech, it is often echolalic. The word 'yes' is absent, but they
may affirm what has been said by repeating it. The pronoun
'I' is also missing. Their bodies, though b e a u m y formed, are
often stiff and unresponsive to the touch and they avert their
eyes h m looking at people. They are often fascinated by
mechanical objects and do not use soil, cuddly toys. Their faces
are sensitive and intelligent, with eyes which look either dead
or exceedingly mournful. Their fingers are deft, their leg and
body movements nimble and graceful. They are insistent on
the preservation of 'sameness'.
Some of these features are characteristic of other E.S.A.
children. In making a diagnosis, it is the symptom combination
which is important, combined with certain details of the early
nurturing situation. In relation to this latter point, there may
be a history of overt depression in the mother when the child
was a young infant, usually of a type which was not incapacita-
ting enough for her to be hospitalized. The mother may not
report that she was depressed, but there may have been
insecure-making circumstances at that time, such as the hus-
band being absent or unduly pre-occupied, or there may have
been interfering relatives who undermined her confidence in
her capacity to be a mother, or there may have been changeful
housing conditions. The parents of such children are invariably
concerned and responsible people and the marriage is usually
relativelystable.
John in Chapter Two was a clear example of Ewly Infante
A u h . On the basis of intensive psychotherapy with such
cases which has resulted in considerable amelioration of their
condition, I want to make some suggestions concerning the
possible etiology ofthis disorder.
A syndrome so specific and so rare is probably the result of
an interacting concurrence of several factors, the likelihood of
their occurring together being a remote chance. On the baais
of clinical evidence, I suggest that some of the operative
factors in the symptom combination of Early Infantile Autism
might be the genetic ones of a good or high intelligence poten-
tial in a child who has an innately good aptitude for the recog-
nition of pattern and form, and also hyper-sensitive responses
to sensory stimulation; such a child being reared by parents,
particularly mothers, who have marked character traits. In
the light of the hypothesis concerning pathological autism in
general which has been developed in earlier chapters, I suggest
that a child who haa the above featurea is particularly prone to
oral separation trauma and is a 'tricky' infant to have to rear.
Evi&nc~for a High Intelligence-Potential
When the children I have treated began to function norm-
ally they were very intelligent. The few children who have
been reported to have recovered spontaneouslyhave obviously
been of high intelligence. One became a mathematician,
'having completed his undergraduate training in mathematics
at one of the nation's foremost universities in three years'
(Rimland 1964, p. I). Another became a meteorologist,
another a composer. Many workers think that the reported
casa of 'idiots savants' are 'recovered' autistic children. A few
children develop along a very narrow line. I well remember a
four-year-old boy, at the Putnam Center, who could do fan-
tastic arithmetical calculations involving thouaands in his
head. He could not have developed this intellectual ability,
distorted though it was, unless he had had some inbuilt high
aptitude. (His father was a high-powered mathematician.)
Those children who use speech usually have a history of its
early development. Words are learned quickly, and the child
is suddenly found to be using complete sentenca before he is
SPECIFIC SYNDROMES
one year old. As well as this early usc of language, early or at
least undelayed motor ability is reported. Some children have
delayed walking until they can do it perfectly. This is charac-
teristic of highly intelligent children who delay speaking and
walking until they can achieve somethinglike that done by the
grown ups around them. They seem to have a model of the
performance and to be unwilling to put their skill into effect in
the outside world until they can achieve consonance with this
model. When autistic children begin to draw, they display
similar behaviour. If the representation they draw on paper
does not sufficiently conform to the picture they envisaged in
their mind, they will tear up the picture in distress and rage.
This lack of fit of the outside world to the child's own pattern
seems to be the crux of the problem at all levels. I suggest that
this is partly due to an acute and precocious capacity for
discrimination due to high intelligence, hyper-sensitive
sense organs and possibly an innate feeling for pattern and
shape. (These children almost invariably show evidence
of having artistic gifts when they come out of their autism.
Rimland says that such children when tested show a par-
ticularly marked aptitude for the recognition of pattern and
shape.)
Intelligence is an omnibus of capacities, but the capacity
to make fine discriminationsis undoubtedly one of its features.
A highly intelligent child with a marked aptitude for the
recognition of pattern and form might discriminate very early
and so be more aware of lack of fit of correspondences to innate
forms than a less intelligent child would be, with the conse-
quent uprush of panic and rage which we have seen to be
occasioned by this. Ultra-sensitive sense organs would also
reinforce the making of acute discriminations earlier than is
normal. Bergman and Escalona (1949)attribute the appear-
ance of early discriminatory functions in the children they
observed with unusual sensitivities, to lack of an 'uninter-
rupted safety of maternal protection'. (Rimland classes the
Bergman and Escalona children as cases of Em& Infan*
A u h according to his strict diagnosticcriteria.) I suggest that
such a capacity for discrimination would only be likely to
develop in an infant who already had a good intellectual
endowment. As a modification of Bergman and Escalona's
hypothesis, I would suggest a contribution to the disturbance
from the child's side. The making of too early discriminations
by a highly intelligent infant would disturb the illusion of pro-
tective continuity with the mother and cause unbearable
awarenessof bodily separateness, resulting in separation-fright
and all the features associated with it that have been described
in previous chapters. (Bion's 'nameless dread' being an out-
standing feature.) This causes the child to withdraw from the
mother who, for various reasons, may be somewhat insecure
in her mothering. This causes the vicious circle of abnormal
secondary autism which makes these children so difficult to
treat.
The fact that autistic children are predominantly first-born
males is significant, in that boy children are more difficult to
rear than girls. Also mothers have special feelings about giving
birth to a boy and, in the depths, may feel that they have lost
an important masculine part of their bodies. There is also the
fact that most mothers are more uncertain in handling first
children than handling those who come when they are more
experienced.
The Mothers of Autistic Children

Time and again, I have flinched at the stereotyped descrip-
tions of the mothers of autistic children, such as 'refrigerator
mothers', 'overly objective', etc., but the parents of children
manifesting the symptom combination of early childhood
autism do seem to have specific traits in common. For one
thing they are almost invariably of good or very high intelli-
gence. Kanner spoke of them as being 'disdainful of frivolity',
and 'quiet and serious'. He said they were 'painstaking and
accurate informers'. They tended to direct their activities
towards specific goals in a persevering way and to be relatively
SPECIFIC SYNDROMES
indastrictible. They had high standards and were perfec-
tionists (Kanner I 957).
These specific character traits were confirmed by Rimland.
He places these parents amongst a small group of kretschmer's
cyclothyrnes who are 'cats who walk by themselves', 'people
who take things rather to heart' and 'like to live their lives
quietly and in contemplation' (Rimland 1964, p. 162). This
coincides with my own experience of these parents, in par-
ticular the mothers.
When the children come out of their autism they manifest the
same qualities. They show evidence of being very persevering
and extremely logical. They listen carefblly to interpretations,
occasionally correcting them usually justifiably, or they may
point out subtleties that I have missed. Their concentration
on the therapeutic work is most rewarding and stimulating.
Although I can confirm Rimland's finding that mental
illness is rarely reported in the families with children suffering
from early childhood autism, it has been my impression that
the parents, in particular the mothers, have to expend con-
siderable energy, as well as courage, in keeping depression at
bay. I well remember the mother of one autistic child who
telephoned me during one of the early week-end 'breaks' in
the treatment of her child, to say that he was provoking in her
'that dreadful blue mood' when she felt likejumping out of the
window. She could not be like that, she went on, or she would
be no good to her husband or to her child. Another mother
told me of a time when she felt 'frozen in aeons of space'. This
highlights the need of the mother (and father) to have support
whilst the child is in treatment for, although the child is not
overtly responsive to the mother, there is a strong underground
involvement between them. These children are forceful in
their projections and can affect the emotional climate of the
family, as well as the family's emotional climate affecting
them.
It has seemed to me that the mothers of these children often
have intense mood swings beneath their controlled exteriors.
(Rimland's placing them in kretschmer's cyclothymes indi-
cates this.) They seem to have dealt with their tempestuous
natures by damping them down. When they give birth to a
child who is far f h m being phlegmatic in temperament, and
forceful because of high intelligence and a passionate nature,
they find it difficult to bear the push and thrust of the infant's
intense feelings. This combined with undermining outside
circumstances may mean that the child's development goes
along a deviant pathway from which retrieval is difficult.
I find the courage and the heart-break encountered in these
families both moving and stirring: they stir strong feelings of
compassion and therapeutic ambition. The child (usually a
first child) who was to fulfil the parents' most cherished and
perfectionist expectations, for some unknown reason fails to do
so and becomes a creation of which they are ashamed. The
mother feels that the exciting thing inside her has become a
catastrophe; as one mother expressed it to me, 'The messianic
hope has ended in a cross.' The child often seems to come to
represent for the mother (or both parents) the incorrigible
impulse-dominated bit of themselves which will not learn and
will not think, of which they are ashamed. They increasingly
withdraw in spirit, if not in body, from a child who needs extra
specialresponsiveness.
In their efforts to bring the child nearer to their expectations
they tend to instruct him in things which are beyond his age
and capacities. Thus, they impose a too advanced way of
behaving on an already terrified child who is in an over-
sensitized state. In despair, the child reacts with negativism.
He shuts things out, because from all sides he is being asked to
take in too much. One autistic child who recovered spontan-
eously expressed it later as having 'a tight ball of worry in my
mind which I couldn't change into thoughts, so I expect I
pulled out'. This 'pulling out' may be part of a healthy in-
stinct for survival-an opting out until more propitious
circumstances for growth arise, a kind of lying dormant. The
trouble is that the autistic processes associated with the with-
SPECIFIC SYNDROMES
drawal can become so habitual that the child reaches a state
of being out oftouch with human aid. I t seems to be the defence
mechanism of an original and independent personality, unlike
the schizophrenic who, by splitting and projective identifica-
tion, disperses himself amongst the crowd to remain a vague,
shadowy, indeterminate figure, 'one of the crowd', often of an
'inadequate' type.
In the past the 'so-called' psychogeneticists have seemed to
'blame' the mother for her autistic child's disorder. As we have
seen, such mothers have a good deal of depression about the
discrepancy between the vision of what they would like to
achieve and what, as ordinary, though talented, mortals they
can achieve. Thus, this 'blame' has been particularly hurtlid.
It has also rubbed salt into the wound caused by the child's
withdrawal h m them. As Tischler (1964) has shown ao
movingly, they have suffered great stress through years of
being rebuffed by an unrewarding and unresponsive child.
Although they may be good parents, they are never as good as
they would like to be. Their autistic child seems to them to be a
living, breathing embodiment of their failure.
The hypothesis concerning the possible etiology of Ewlg

Infant& Autism which has been presented in this chapter makes
sense in terms of the behavioural and clinical features that are
characteristicof the syndrome. In particular, it fits in with the
twin evidence collected by Rimiand, He found that eleven of
the fourteen pairs of autistic twins were identical. In contrast,
the six reported studies of schizophrenic twins show that they
follow the usual ratio of two or more dissimilar pairs for each
identical pair (Rimland 1964, p. 75). This seems to be power-
ful evidence for a genetic factor, or set of factors, being in
operation in Early I n f d k A u h . It could also point to the
operation of nurturant factors which are very close to the
mother-infant situation. Although, even in the early months,
each twin is not likely to have identical nurturing or to have
had the same intra-uterine situation, the important factor of a
depressed or uncertain mother is likely to affect them both.
The hypothesis developed in this chapter suggests that there
may be an intertwining of genetic factors with just such an
early nurturant one.
Rimland uses the twin evidence to differentiate between
Early Infantile Autism and Childhood Schizophrenia, and as
evidence for an organic factor being in operation in the former
syndrome. He suggests that the single basic cause of early in-
fantile autism is damage to the reticular formation in the brain
stem, the cells of which he maintains are similar to those in the
retina. He suggests that just as there is damage to the retina in
Retroldal Fibrophasia by the over-enthusiastic administration
ofoxygen at birth, damage to the reticular formationof autistic
children may have been caused in the same way. Since there
are many cases of early infantile autism where oxygen was not
administered at birth, he suggests that these children were
susceptible to the oxygen of the air! This hypothesis, apart
from being far fetched, overlooks the fact that there are no
spontaneous recoveries from Retrolental FibropAan'a as there
are from Early Infantile Autism.
Creak (1967) suggests that there may be 'a built-in failure
to incorporate a system of response to stimuli'. Rubinfine
suggests intra-uterine factors (although in the case of the
identical twins these would have to affect both embryos).
O'Gorrnan (1967) suggests hormonal factors. All these pos-
sibilities are tenable, but the children who recover spon-
taneously or who respond to education or psychotherapy must
have found some way around these basic defects, if they were
present.
The conflict between the organicists and the psychogene-
ticists is often a false one. The present uncertain state of our
knowledge concerning the interaction of neural structure and
psychological functioning means that the distinction between
organic and psychogenetic factors has very little useful rele-
vance except in cases of gross and obvious brain damage.
SPECIFIC SYNDROMES
Disturbance in development in early infancy can cause im-
pairments which seem almost constitutional. Throughout life,
neurological factors are reflected in emotional life. Whether
we speak of psychogenic or neurophysiological factors often
seems to be a matter of what level of discourse is being used.
Some people prefer one and some the other. Perhaps the acid
test will be if one level of discourse leads to more effective
methods of treatment so that the lot of these unhappy children
and their distressed parents is improved.
SUMMARY
Early childhood autism has been discriminated as a specific
syndrome of an E.S.A. type. I t has been suggested that its rare
occurrence may be due to its development being the result of a
concurrence of several factors which rarely occur together.
Clinical work suggests that some of these factors may be good
or high intelligencepotential, a marked capacity for the recog-
nition of pattern and shape, and hyper-sensitive sense organs.
It is suggested that such a child is prone to oral-separation
trauma, and that the depressive nature and undue rejectability
of parents with high standards for themselves makes it difficult
for the child to emerge from his shocked withdrawal. Once a
state of pathological autism is under weigh it is difficult to
reverse, for it is self-perpetuating and self-aggravating. The
possibility that autistic children have some inborn defect is not
ruled out, but it would seem that the children who recover,
either spontaneously or as the result of education or psycho-
therapy, have found some way around this impediment, if it
exists.
Ewlg Infanttile Autism
I. Withdrawal dates from early I. Severe symptom follow a
infancy. period of normality.
I. May have early history of 2. The pre-schizophrenic child
screaming and tantrums. is ' d e s t to care for, the
moat quickly trained, the
cleanest, and in short nearly
a perfect infant' (Rimland
1964, P. 69, quoting from
many other authors).
3. Have exceptionally good 3. ORen in poor health;
health from birth. Sign of respiratory, circulatory,
progress when they begin to metabolic and digestive
have the ordinary infections difficulties very common.
and il1naw.a of childhood.
4. Bodies are stiff and 4. When held 'mold' themselves
unrcaponsive. Do not adapt 'like plastic or dough'.
themelves to being held. Display 'empty clinging' and
burrowing into people.
5. Very averted from any form 5. 'Contact is pathologically
of contact with other people. invasive' (Bender).
6. Eyes averted from looking at 6. Eyes unfocused. Seem to
people. look through rather than at
people.
7. Inhibition of thinking. 7. Corlfusionof thinking.
8. Virtually no fantasy play. 8. Much confused and
primitive fantasy play.
g. May be mute or echolalic. g. Speech slurred, confused or
Absence of words 'yes' and prolix.
'1'. Affirmation by repetition.
10. Graceful, nimble body 10. Loose, uncoordinated oRen
movements; deft linger clumsy body movements.
movements.
I I. Spinning of objects very deft. I I. Qumsy spinning of objects.
19. Feather-light touch in the 12. Blunt-fingered, clumsy
manipulation of objects. manipulation of objects.
15. May lack sensation in fingem I g. Lack of sensation in bodily
and toes. extremities ir common.
DIFFERENTIAL FEATURES
Ewlg Infwtrils Autism C h i l h d Schizophrenia
I+ ..
'The autirtic child u I+ '...
the schizophrenic child
unoriented, detached, appeata to be dhrientcd,
appearing disintemted in wnftned and anxiow, and
the events around him and oRen expram deep concern
more aloof from and oblivious about his relatiomhip with
to the environment than in hir environment. He d u
contact with it' (Rimland he is confiued' (Rimland
I& p. 74). (My italics.) 19649 P. 74). (MYitalics.)
15. Good or high intelligence 15. Varying potentialities of
potential. intelligmce.
16. Marked capacities for the 16. Varying capacitia for the
recognition of pattern and recognition of pattern and
bpe. hpe*
I 7. Hyper-aenaitive KXUC organs. 17. ---
18. U~uallyhave high 18. Family background much
educational and intellectual more varied.
family background.
I g. Familia h o w a low incidence I 9. High incidence of revere
of mental b r d e r . mental disorder.
20. No awarenaa of bodily 20. Comtant blurred awarcna
lupamtenaa except in of bodily neparatena8.
tran8itory 'anatches'. F d n g a of confiuion.
21. Almont invariably fascinated 2 I. Not invariably fascinated by
by mechanical objects. mechanical objects. May ure
Peraeverating use of autirtic a t r u m i h d object and be
objects. unduly attached to it long
after the age when t h e are
n d y given up.
2s. A frightening object may be 22. There children have
divided up into separate a r d v e l y split and dupened
parts and brought together parb of themaclvca to
by a child for whom it reemr become confiued with other
more manageable for he f e d people in order to avoid
he has made it up h i d . lrwarcnegofbodily
qaratmeM.
23. T h m children have opted 23. Thae children have become
out. confured.
24. Arrested development. 24. Rcgrcancd development.
25. From the child's point of 25. From the point of view of
view the mother acema to the child, the mother reemr
have c h d down as the tobetooopnrastheraultaf:
rault of:
Early Infdk Autism Childhood Schizophr&
(a) The child's withdrawal from (a) The child's e x d v e
the mother. invaaiveness.
(6) Mother b withdrawn by (6) The mother being codbed
nature. and in a muddle.
(G)Mother is deprcascd or (G)The mother being seductive
preoccupied. and over-indulgent towards
the child.
26. Operate on basin of 26. Operate on b& of minute
dichotomy between splitting (fragmentation).
prematurely assembled 'self'
and outside object. 'Self' is
'messfrightening outside
world ie 'not-me'. 'Not-me' is
blotted out, thua there b no
awareness of 'self'.
27. Processes of extrusive and 27. Processs of projective
intrusive envelopment have identification described by
persisted and become Klein have become excessive
excessive to deal with to avoid awareness of bodily
traumatic experience of separateness. Dr Herbert
separateness. hociated with Roaenfeld dcacribea thia in
'flowing-overs which a his book Psychotic Stcrbs
little-known paper by (1965, PP. 170-71).
Herman ( I929) described aa
being the forerunner to
projection.
28. These children are 'wrapped 28. Mother and child are
up in themselves', i.e. the 'wrapped up in each other'.
delusion is that they are Later, these children lore
enveloped in their own body themselves in the crowd m
stuff and in other people that their own identity b
experienced as a uncertain. Became 'so-called'
continuation of their body. inadequate penonalitia.
A CLINICAL D E S C R I P T I O N OF
RALPHwill now be briefly presented as one example of a
schizophrenicchild manifesting Regressive Secondary Autism
(R.S.A.).
Early History
Ralph was a second child born to a couple in Australia. He
was an extremely good baby ('we didn't know we had him'),
and was bottle fed. When he was ten months old the mother
went to take a University course in Psychology in another town
in Australia and the baby was left with the maternal grand-
parents. When the mother returned he was eighteen months
old. She found a child who had had eczema (which had
cleared up) and who was inclined to be 'chesty'. He was also
'whiney' and miserable.
When Ralph was three years old the family moved to
another part of Australia and he was sent to kindergarten.
Here, he functionedlike a mentally defective child, and mother
became very worried, for it confirmed her worst fears, having
been absolutely convinced when she was pregnant that her
child would be subnormal.
When Ralph was six years old the family moved to England
and the mother decided to try to find help for Ralph who was
beginning to live more and more in a world of bizarre fantasy.
I t was not possible to test him but the mother insisted that
she wanted him to have help even if it turned out that he was
intellectually under-endowed. He came to me when he was
eight. From the first it became clear that he had never en-
countered limits and that he lived in a formlessworld in which
he felt he was left to thrash about as he pleased. His mother
told me that if he wanted a certain kind of sweets, she would
put on her coat, get into the car and go looking for them till she
found them. The family were in extremely comfortable finan-
cial circumstances, and most things that he wanted he was
allowed to have.
When I first saw him his skin was grey and crumbling like
dry clay, his eyes were unfocused with blurred rims round the
iris like those of an old man, his mouth was loose and slack.
The most striking thing was his gait. He straddled his legs at
such odd angles that at one time he had been thought to be
spastic. His arms flailed around him as he walked.
Clinical MatGtr'al
He started to play as soon as he reached the therapy room.
In those days I supplied matches and candles in each child's
drawer, and he went straight to these. He played in a way
which made me feel as if a film were being flashed before my
eyes at break-neck speed. He talked all the time, though at the
end I found it difficult to remember what he had said. The
sense was hard to follow, key words were left out and his voice
was a dreary monotone which almost lulled me to sleep. This,
with the disconnected sentences, made me feel far away from
him and in a state of utmost confusion.
I now want to bring some sequences from this early play. He
had wanted to wander in an invasive fashion into other parts of
my house. The one clear point that emerged out of a plethora
of confused talk about this was that he wanted what he called
'that extra bit'. In the therapy room he lit a fire in the metal
waste-paper bin. He danced around this as if in an orgy, with
saliva running from his mouth and his arms and legs thrashing
like those of a primitive savage. His eyes flashed with preter-
natural brilliance very different from their usual dull appear-
ance. When the fire was dying down, the black bits of charred
paper were sent up in the air as he stirred them with a stick.
These pieces of black paper were all right if they went back into
the metal bin, but he was very frightened of those which over-
flowed and blew about the room.
The next day he rushed into the therapy room saying, 'I
want the black board.' On this he hastily drew two long narrow
rectangles and a smaller one, saying, 'mother', 'father',
'sister'. He then rushed from the room saying 'Do them!' He
went to the lavatory where he did a large sloppy motion on the
black seat which covered the pan and which he did not lift up.
He was upset about this and Frightened of the motion. He then
tried to cover it with lavatory paper, but it flowed round the
edges. He was obviously very frightened by this part that
would not be contained by the paper and retreated from it in
terror.
As I cleaned up the mess and put it into the lavatory pan, I
interpreted his fear of the part of himself which he felt was
allowed to get out of control and to have the 'extra bit'-was
allowed to intrude into the parent's private parts and 'do' the
family. He felt it was dangerous to himselfand to his family.
After this he breathed out of the window in the therapy
room. I t was a cold day and his breath came out like smoke or
steam. He then shut himself into a cupboard in the therapy
room saying that he was a dragon with dangerous breath. He
said the cupboard was 'full of babies'. His breath burned them,
the cupboard, and himself. He only escaped 'by a rubbing
magic'. It was clear that he felt that the substances which
seemed to escape so easily from the uncertain confines of his
body were dangerous. I interpreted that he felt he entered me
as the cupboard mummy full of babies and enviously burned
them up with his burning breath. He was then afraid that he
would be burned up and could only escape by the magic of
rubbing his penis which he felt could make anything happen
that he pleased.
The next day he entered this cupboard as a 'brown gorilla'
and waved his arms and legs about saying he was dropping
'plops'. I interpreted that he wanted to upset my babies by
stirring things around inside my cupboard (my tummy) and
A U T I S M A N D CHILDHOOD PSYCHOSIS
dropping 'plops'. He said, 'But bits get out of the cupboard and
are dangerous.' I remembered the black bits of paper which
had floated around the room. I reminded him of this and said
that if I did not hold him firmly and stop him from upsetting
my babies-upsetting the brain children in my mind-then
he felt that dangerous bits of his body ('plops' and 'wees' and
breath) escaped and threatened us both. He left the room
walking in a more co-ordinated way.
This improved bodily co-ordination was the first sign of
improvement. Over a period of five years of five-times-a-week
treatment this boy came to live in the more ordinary world of
everyday events. He became more socially adjusted. His treat-
ment was studded with gaps due to physical illness and he is
still liable to outbreaks of physical illness in reaction to undue
and sudden stress. He was in a Day Unit for the care of very ill
children which had an inspired headmaster. He never used his
intelligence to anything like the extent to which I sensed he
was capable. (If I saw him now I feel that I could help him
more with this.) However, he is able to hold down a job as a
postman, although he does not seem likely to marry. The
parents, in particular the mother, have provided important
emotional support and environmental management without
which he could not have managed so well. Fortunately, his
parents can leave him well provided for and they are thankful
to have a son who is much more normal than they had ever
dared to hope. Without treatment he would have had to live
in an institution. As it is he can live with his family without
shaming them by seeming odd.
PrecipitatingFactors
Before discussing this clinical material, let me summarize
the factors which seemed to have caused Ralph to get into the
confused psychotic state in which I first saw him. First of all, as
we know, the 'unusually good baby' type of history is often
ominous. (When I knew him, Ralph alternated between
being passively compliant and controllingly thrusting.) There
was a history of schizophrenia in the family. There was also
the separation from his mother when he was ten months old,
the moves from one place to another which would be upsetting
to an infant who, due to constitutional and environmental
factors, tended to be emotionallyfragile. At the time when they
came to see me, there was his mother's over-indulgence which
I should imagine had been a factor, in some measure, ever
since he was a baby. In the course of her discussionswith a very
skilled psychiatric social worker she became firmer and less
complianttowards him, and this greatly helped his escape from
entanglement with her in a world of queer fantasy. Prior to
this, I am sure there had been a good deal of the 'double-
blind' type of communication from mother to son which had
increased his inanition and confusion.*
DISCUSSION O F THE CLINICAL
MATERIAL
There is much that could be discussed in relation to this
boy's material but I want to use it to illustrate certain points.
The first of these is that although fantasies have developed in
the R.S.A. child, they are still closely associated with bodily
substances and bodily sensations.
It also illustrates the intrusiveness of R.S.A.children and
the way in which they try to block the baby-making capacities
of the cupboard mother. (I suspect that this was a very early
'cupboard-love' mother. The orgiastic salivating around the
bonfire suggests this. In these children, development seems to
have got out of phase; phallic impulses emerging too soon and
becoming confused with oral ones.)
It also illustrates the burning envy of the children in this
state of regressive autism and the 'spoiling' associated with
* This mother showed great courage in facing and dealing with her
own problems. Without her dedicated co-operation, Ralph's resulting
state of being able to live in the community would not have been
possible.
Also the inaighdul care given by Mrs. Carol Flynn has provided an
enabling setting for the psychotherapeutic treatment of several
psychotic children.
this. Francis Bacon writes of envy as 'an ejaculation of the eye',
and eyes seem to play an important part in envy. Ralph often
seemed to bore into me with burning envious glances.
Material from psychotic children has led me to think that
primary envy may develop at a later stage than jealous posses-
siveness. Envy seems to require more sense of separateness
than possessiveness. The disintegrated R.S.A. children have
functioned in a more differentiated way than the E.S.A.
children have ever done. They often show possessiveness
towards their mother as well as envy of the parents' relation-
ship. One such boy saying openly, 'I want to marry my mother
and never to leave her.' The E.S.A. children manifestjealousy
as they come out of their withdrawal, but envy comes up
later, although it is rarely so intense as with the R.S.A.
children. Perhaps this may be because, as Meltzer suggests
(using his distinctions of autistic and schizophrenic), the
E.S.A. children (autistic) have warmer natures than the
schizophrenic children (who come into the R.S.A. category).
The clinical material also illustrates the way in which the
R.S.A. child produces deep and primitive material from the
word 'goy-in fact they are too 'openy-whereas the E.S.A.
children may take up to a year or even more before they start
to play in a communicating way.
Chapter Eleven
A SETTING FOR PSYCHOTHERAPY

A PSYCHOTIC child's first and most urgent need is to feel that
the explosive violence which threatens to burst everything
apart can be held and contained within a setting which can
bear it. Any method of treatment needs to take into account
that at mot such children are terror-stricken. Every particle
and cell in their body seems to have been touched with a potent
irritant. As one recovering psychotic child said, 'It was like
hobgoblins in the blood.' After the rage and terror have been
worked over and abated, the child may go on with autistic
habits, simply because they have become habitual and firm-
ness is needed to help him to give them up.
Psychotherapy is one way of treating such children and
there are many methods of psychotherapy. My own method
which is psycho-analytic is based on the work of Melanie
Klein.
Treatment Setting
In this type of psychotherapy, the child is seen at the same
time each day (if he is seen daily), or at the same time each
week (if he is seen weekly). If he is seen only once a week it is
helpful if he attends daily at a special unit where the teacher
provides a predictable and supportive setting. During the
therapeutic session the child remains in the same room all the
time. He is not allowed to wander around the clinic. The
arrangements of the room are kept the same from session to
session. He had his own drawer of toys which is locked after he
goes. These are simple toys such as wild and tame animals,
figures to represent a family, cars, a wooden bridge, paint and
crayons. There is also a tap with running water in the room.
The important non-tangible feature of being held within the
orbit of the therapist's vigilant and constant attention com-
pletes the containing setting. The therapist does not leave the
room, answer the telephone, eat or drink, or move in any
sudden way. The other important non-tangible features is that
brief, concise interpretations and comments are used from the
beginning of treatment. One value of an attentive and inter-
preting therapist is that the child gradually experiencesboth a
listening and speaking object. Both these activities are signifi-
cant in helping him to begin to speak, listening being the most
important.
Interpretations have another value. Psychotic children keep

experiences discrete and separate from one another; they do
not seem to be able to link them together and interpret them.
The interpretive process seems to supply such a child with just
what he lacks. The objection may be made that, at the begin-
ning of treatment, the child has little understanding of words.
My experience is that there is a segment of awareness which
understands far more words than we realize, as witness the
mute autistic child cited by Rimland, who in the moment of
panic when a prune skin was stuck in his throat, gasped, 'Take
it out !' (Rimland 1964,p. 15.)Also, in making interpretations
it is important to choose words carefully, with a mute child
interspersingthe words the parents think he understands. With
all such children it is important to make interpretations short
and to the point and not to be afiaid to repeat the same thing
over again either in the same way or in a slightly different way.
One of the therapeutic features of this approach is that the
child seems to realize that someone is trying to get through to
him, is bearing the frustration of his lack of response, and is not
put off by it but keeps on going forward. The autistic child
can often bear this verbal forward movement on the part of the
therapist more than physical contact. In my own work,
especially in the early stages of treatment, I have learned to
keep bodily contact and even gestures to a minimum since they
seem to excite the child so that he freezes up, or else make him
hyperactive. Talking does not seem to have this effect,
although sometimes the child feels persecuted by words and
feels that they are solid objects being pushed into him. In such
cases, this is interpreted and, if it is done carefully, almost
invariably it brings great relief to the child who begins to move
from a concrete level offunctioning.
It seems as if the therapist provides him with an auxiliary
agent ofinterpretation until he can begin to do this for himself.
The therapist acts as if to say, 'Rather than lend you my hand
as ifit were a part ofyour body, I will lend you my "thinkings"
which will help you gradually to differentiate your body from
mine and to develop "thinkings" ofyour own.' The interpreta-
tion of primitive bodily states requires the capacity to enter
into someone else's physical states without losing one's head.
The capacity for imaginative reconstruction of primitive
experience is important in therapy with autistic children. The
putting of these reconstructions into words is helpful to both
therapist and patient; the latter gradually 'gets the hang' of
this process and begins to do it for himself. He begins to be able
to interpose words and, later, thinking (internal speech)
between the impulse to action and its execution. The thera-
pist's capacity to i&flet seems to provide a mental apparatus
(until the child can develop one of his own), which enables
tension to be sustained and action delayed in terms of outside
possibilities and his own capacities. By using the therapist's
mind as an intermediate, auxiliary agent, somatic processes of
immediate discharge gradually become transformed into
mental states. This is a step which autistic children have been
unable to make. It is the essential core of the arrest of intellec-
tual development.
The inability to communicate adds to the terrors of the
state of pathological autism. The therapist has to act for the
patient in this regard until he can begin to use the evocative
symbolic expressions which enable him to give form and shape
to the nameless invisible terrors which arise from the depths of
the mind to beset us all. The therapist's intuitions based on
experience with other patients, and feelings stirred up by this
patient, preferably checked with analyst, supervisor or col-
leagues, are a source of inspiration for interpretations during
this difficult first period. The possibility of talking over the
child's behaviour with another person is an important support
for the therapist for, until he is very experienced, it is diflicult
to contain the intense primal fears and excitements stirred up
by these children if they are being treated on the basis of iden-
tifying with them.
The checking of the therapist's intuitions with other
workers is important for another reason. Very often, the
mothers of these children have not so much failed to respond to
communications but have responded too quickly to com-
munications which did not come through normal channels.
They have been unduly 'telepathic' and have responded to
bodily modes of communication as if their body was part of the
child and the child's was part of them, at a time when this mode
of response should have been being given up. This has con-
tributed to the child's becoming 'lazy' about developing the
more normal ways of getting in touch with other human
beings. These abnormal modes of getting in touch with other
human beings were described in the chapter on autistic pro-
cesses and seemed to be based on the excessive use of the capa-
city to 'feel with' another person. Thus, the therapist needs to
curb any 'witch-like' tendencies to give interpretations for
which evidence cannot be found in the child's material, even
though this is likely to be more slender evidence than would be
used in work with a neurotic child. This prevents the child's
magical beliefs from being reinforced. Thia does not mean that
counter-transference manifestations are excluded, it merely
means that they are kept within bounds, so that what is
interpreted to the child is based on evidence which could be
demonstrated to him and to other insightful workers if need
be.
An objection to the use of interpretation with these children
might be that, in the early days, we are dealing with non-
verbal, acting-out levels in which actions speak louder than
words. This is true. But the very act ofinterpreting is an action.
It establishes that talking is the commonly accepted mode of
communication between ordinary human beings. Thought
transference and telepathy, even if such processes are possible,
are not ordinary methods ofcommunication. In the treatment
of psychotic children, the therapist should be chary of feeling
that he is using them. These children are already extraordinary
enough.
Work with Par&

An important point that psychotherapists can learn from
Behaviour Therapists is that the parents should be co-workers
in the reclamation of the parts of the child's personality which
have gone to waste. Parents who have taken the trouble to seek
treatment for their child are willing to cooperate, even though
they may have other feelings when the child has difficult
phases or when they feel that the child is getting the kind of
help they themselves would have liked to have had as children.
My own experience in working with parents when children
were seen in private practice, is that it is helpful if the thera-
pist's and parents' contributions are clearly delineated and
differentiated. The therapist makes it clear that she does not
take over the r61e of being mother to the child in the present-
day situation. She will help him to relive infantile states in
relation to her, but this enables his present-day use ofhis actual
mother to be made easier. The r6le of the parents is to assist in
the firm containment of the child, and in being willing to
respond to his overtures as he begins to make them. Parents
who have sought treatment for a child are only too willing to do
this. They also begin to realize that it would be inappropriate
for them to take over the therapist's r61e in relation to their
child, although, at first, many parents feel they would like to
do this. Gradually they come to realize that this d l e is an
extremely limited, somewhat unrewarding and arduous one.
They realize that they have not the necessary conditions under
which to function as the type of therapist which has been des-
scribed here. The job of the parents is a much more satiseng
and expanding one. One mother whose child was in treatment
used to telephone me saying, 'I think this is your department.'
This delineation of r6les has seemed to me to keep the channels
of communication between therapist and parents relatively
clear. We have not unduly 'stood on each other's toes'.
As we have seen, these children severely sap the caring
person's confidence both by the violent feelings they arouse by
their non-response and because care is repudiated. It is no
wonder that when the parents of such children (particularly,
the mothers), come to helping agencies, they are doubtful
about their capacity to be mothers, and are easily hurt by what
is said to them, particularly ifit is implied that they have been
'bad' or inadequate mothers. As the result of hurtful experi-
ences at the hands of psychotherapists, some parents are bitter
about this form of treatment. (See Rimland 1964,p. 65.)
In my own experience the mothers of these children have
often been under-confident about being mothers, or confused
or muddled or sad. Many of them have seemed panicked by
their children, all have been concerned people and some have
been overawed by the responsibilities of being a mother. I t is
natural that they will feel some envy towards a therapist when
she seems able to do for the child what they feel they have failed
to do. But their pleasure in having a recovering, co-operative
child invariably outweighs this.
Parents and clinic workers are engaged in a difficult enter-
prise which requires great dedication. It is not helpful to the
therapeutic endeavour if the parents' confidence is under-
mined by the therapist or other workers in the clinic. Similarly,
it is not helpful to the joint enterprise ifthe parents undermine
the therapist. These children and those who care for them
have to bear emotional states which, in their intensity, are
out of the run of ordinary experience. The grown-ups need
to form a circle of linked hands around the child whilst he
lives through these intense feelings and to support each other.
The father, in particular, can often give much needed s u p
port to the mother. Cases in which the father has been a fully
cooperating member have moved rewardingly. If the mother
has no husband it has seemed best for the child to be in resi-
dence, possibly as a weekly boarder, in a special unit for
autistic children. On one occasion, mother and child lived in a
mother and baby unit of a paediatric ward before going to live
with a very supportingfamily where there was another young
child. (This unconventional help was made possible by a very
humane and enlightened paediatrician.) In all cases, help from
a skilled psychiatric social worker or psychiatrist is of
inestimable value.
Conditionfor the Can ofPsychoPicChildren
Work with such children makes heavy demands on staff
devoted to their care. An over-competitive atmosphere in a
group of workers makes work with these children difficult, if
not impossible. The worker who uses his own vulnerability to
understand these over-vulnerable children can feel psycho-
logically bruised by a group in which over-ambition and
political manaeuvring is rife. In such a group human frailty
and fallibility are despised as signs of weakness to be exploited :
needling in tender spots is the order of the day, however much
it is disguised under a civilized exterior. A single indiviudal,
even one whose inner integrity is sure, cannot always bear the
powerful rages, terrors and grieii let loose by these children.
He needs the support of a well-integrated and mature group
of professional colleagues. This demands an unusual degree of
kindness and forebearance on the part of the workers involved.
In his turn, the individual workers has to be able to admit his
need for support from others. His own autistic bluff has had to
be called. In short, all those who work with psychotic children
need a high degree of both inner and outer security if they are
to function in a way which is helpful to the child and not per-
manently damaging to themselves.
Psychotic children seem to thrive best with people who as
well as being sensitive are also sensible and straight-forward.
They do not deviously manauvre the children nor allow
themselves to be deviously manauvred. By simplicity and lack
of pretension and artificiality they hope to enable the children
to become more in touch with themselves and with the outside
world.
Those who have worked with psychotic children know that
response to them must be firm, consistent and confident.
Their over-riding need is for someone who cares for them even
though they try to elude care to perseverate with their own
autistic devices. On the other hand, undue 'prodding' of the
child into action does not seem likely to achieve its purpose.
The caring person has to 'play it by ear' and preserve a balance
between letting the child 'be' and helping him to move forward
by establishing that outside people are not part of his autistic
system. As in all caring involved-detachment is the aim.
Chapter Twelve
PHASES IN PSYCHOTHERAPY W I T H
PSYCHOTIC CHILDREN
INthh chapter various phases of the psychotherapeutic pro-
cess with psychotic children will be described. These will be in
the sequencein which they are likely to occur when treatment
is carried out in the firm containing setting described in the
previous chapter. In this manner of presentation, treatment
will seem to be much more easy, smooth-flowingprocess than
it actually is. In practice, one phase overlapswith the next one,
and there are set-backs in response to such events as holiday
breaks or disturbing happenings at home or at school. How-
ever, in looking back over the whole course of treatment the
following phases can be discerned in therapy with E.S.A. and
R.S.A. ( I ) children.
PHASEI
This is an extremely difficult phase in that we have to
attempt psychotherapy with a child who to all intents and pur-
poses has very little psychic life other than that of sensation, in
which, in some cases, he has lived too much. The feeble flame
of his psychic life has to be fanned by every means at our dis-
posal. He has to be helped to respond to the outside world in a
more realistic way. Autistic objects have to give place to tran-
s i t i o ~objects
l and finally to symbolformation. This often has to
be done whilst we become increasingly aware of our own
insecuritiesand uncertainties.
As we have seen, for some of a variety of reasons the recep-
tion of nurturing has been blocked. Normal attachment
processes of flowing-over-envelopmentand/or projective iden-
tification (whatever it is called) have developed in an over-
reactive fashion to produce the delusion of being inseparably
fused with or attached to a perpetually comforting, satisfying
and supporting object which provides everlasting protection.
This has been a reaction to situations which have been experi-
enced by the child as profound oral frustration imbued with
unspeakable terror. These have been experienced as a blow on
the mouth which brought an agony of consciousness which
could not be borne. The hypersensitized child has to relive
this traumatic fmstration (this 'black hole with the nasty
prick') within the treatment situation.
The first step of progress is when the autistic 'in' and 'out'
reactions of the child gradually become modified to become
reciprocal 'to' and 'fro' responses. At first, this is transitory and
fleeting. This was illustrated by a mute R.S.A.(x) patient
aged six years who had been in once-weekly treatment for a
year and who was also in a small, well-run unit for autistic
children.
Toby had had a phase when he spent most of his time diving
into the couch in my room and rolling about there, often in
ecstasy. He would then point to a dark recess above the door
and then sometimes touched his mouth or his genital, or
both. After this, he would go to the window and wrap him-
self in the curtain. From this envelopment he would look
out of the window.
The gist of my interpretations which were cast in various
ways, was that he was wrapping himselfin Tustin's couch-
in Tustin's curtain-in Tustin's body and looking through
Tustin's eyes (the window) so that he felt safe from the
dangerous things above the door.
Later, I came to realize that, in illusion, these children 'put'
unbearably exciting, agitating or irritating sensations out of
their bodies in order to feel rid of them and to feel that they are
controlled there. These unbearable sensations may be 'put' out
of the window or into a dark part of the room or into the thera-
pist's body or round a bend or corner. These places then
become intensely exciting or dangerous. Also outside can
PSYCHOTIC CHILDREN
become inside, and inside become outaide, with the startling
rapidity of an optical illusion. The spinning of outside objects
often seems to have the same significance. The agitation and
excitement is outside and can be controlled there to some
extent. The fact that the spinning.thingsfall may contribute to
the child's illusion that he can control his sense of bodily 'flop'
by seeing it as being outside his body. (Of course, here are the
elements for drama, painting and writing when fbnctioning is
much more differentiated and much less global and rigid.)
In the clinical material quoted above, Toby approached the
world wrapped up in another body which was used as ifit had
no life of its own and was under the sway of his every whim. He
sampled life at second-hand. Since the therapist is used as if he
were a dead thing, this is a sap'ophytic rather than a symbiotic
type of relationship. If such a relationship is allowed to go on
too long it leads to the child's feeling that he is dealing with a
dead and decaying object. But child and therapist have to go
through this 'saprophytic' stage when the therapist is used as
an autistic or transitional object until the therapist's actions,
comments and interpretations establish that he is alive. This
brings frustration, and the child has the chance to relive the
time when things went wrong and psychotic depression in-
hibited development. As the hole type of depression begins to
be worked over, reciprocal responses to the therapist can be
observed. These are fleeting but h o w indications of pro-
gress. Such a phase in Toby's treatment will now be quoted.
One day, after going through the usual wrapping-up pro-

cedures which have been described earlier, Toby went to
pick up part of a wooden bridge. He then came and handed
it to me looking directly at me. After I had held it for a short
time, he stretched out his hand for me to give it back to him.
This I did. Thereupon he gave it back to me. For some time
we went on playing the game of passing the bridge to each
other. This was the first time he had used the toys in a pur-
posefbl way or responded to me for any length of time.
The piece of Toby's material which was quoted earlier
illustrates very well the 'in' and 'out' type of behaviour (in
which there may be little or no awareness of bodily separate-
ness and outsides and insides, or this awareness may be
restricted to one focal part, for example the mouth, or it may
be flickering and intermittent). In this behaviour the therapist
is used as an inanimate and undifferentiated object which can
be 'entered' and whose attributes can be used, in order to
retreat from the unbearable terrors and hardships of being
ignorant and helpless in a threatening world. The second
piece of material illustrates a movement towards reciprocal
response in which separateness is recognized and attempts are
made to tolerate and bridge the gap between himself and
others. For a short time at least, our mutual dependence is
recognized. There is something which we share. This shared
area between mother and child is the point where communica-
tion begins. The psychotic child has a 'hole'-a gap at a place
which should be a point of contact-a place where there could
be a bridge from 'me' to 'you'. The sensitive areas such as
eyes, nose, ears, mouth, genital are places where this fulfilling
experience can take place, but in the psychotic child, this does
not occur or occurs only in a very restricted fashion.
It will be seen that treatment consists in the therapist's
observing the child's behaviour in minute detail in an attempt
to get in touch with him by sensing the world as he senses it. At
times, particularly in the early days of treatment, but also on
worrying occasions later, the therapist feels completely in the
dark as to what is going on in the child. He can only work on
the uncertain evidence of how he feels towards the patient.
This is useful but such responses need to be scrutinized care-
f d y and used with caution. It is tempting to feel that we know
something about the patient through feelings in ourselves,
when we are really in a state of 'not-knowing', and it would be
more useful to admit this. However, our own responses to the
child are an important part of the situation and, with the help
of rigorous personal analysis and supervision, may be used to
PSYCHOTIC CHILDREN
help us in this difficult first period when there seems to be very
little that we can understand with certainty. Our main feelings
may be those of impatience and boredom. It is helpful to
recognize that just by bearing these feelings we are helping our
patient.
As the child becomes more able to bear awareness of the
frustrations inherent in the treatment situation (for example,
the ends of sessions, absences of the therapist, holidays, the
therapist not behaving as an inanimate extension to his body),
the 'hole' type of depression comes increasingly into the focus
of therapeutic attention. With this, the sessions take on form
and shape. Sequences of behaviour can be observed which
gradually make sense to the therapist who feels more in touch
with the child. A shared area develops between child and
therapist. Communication in terms of action and behaviour is
established; the therapist's comments and interpretations
indicating that talking is the ultimate mode ofcommunication.
These comments-cum-interpretations are short simple des-
criptions of what the child is doing. Such children cannot take
in long intricate interpretations, although they may use the
cloud of words to feel wrapped around by them. They may
also be helped by the feeling that someone is trying to get
through to them.
Pre-spech Communications
The therapist's actions, tones of voice and that which the
child senses about the therapist are the communicationswhich
mean most to the child at the commencement of treatment.
But, now and again, he listens to what the therapist is saying.
After a time, a limited concrete type of language may develop
in terms of the toys. With John of Chapter Two, there was the
'blue mummy cart' with the 'red daddy wheels'. There was the
'cruel red tractor' which ran over things. (Isupplied the words
on the basis of his actions.) There was a yellow plastic car
which had detachable parts which came to represent the
mother he tore to pieces in his rage. There was a doll and a cot.
157
According to whether the doll was in the cot or thrown h a p
hazardly at the side, we knew how he felt about the treatment
'holding' situation. After sudden 'breaks' in the treatment
setting, the doll was thrown carelessly outside the cot. When
treatment was proceeding smoothly and reassuringly the doll
was put into the cot with care. Interpretations from such a use
of toys were based on more slender evidence than is usually
used in psycho-analytic treatment but they established
avenues of communication between child and therapist until
speech began to be used.
Primitive Terrors
For much of the time in the early days of treatment the
child, particularly the E.S.A. child, may not seem to be com-
municating with the therapist at all. It is important to remem-
ber that ostrich-like the child has hidden his head in the sand
to retreat from unspeakable dreads. To put it in another way,
he is wallowing in the primeval slime from which he feels rela-
tively undifferentiated. Gradually the therapist gets in touch
with some of these unspeakable terrors which have been kept
at bay by the delusion of being in complete control by bringing
everything to a dead stop. The terrors interpenetrate each
other but are shot through with the supreme dread of helpless-
ness. In a state ofcomplete helplessness, he feels he will be over-
whelmed by endless blackness and darkness, or he will be
irremediably battered and hurt to the point of irreparable
collapse, or he will fall for ever, or he will be swallowed up by a
mouth-like mother who is overwhelmingly engulfing. The
emergence of the notion of a father-element mitigates these
fears. For various reasons, different for each child, maleness
has not emerged as a supportingand integrating element.
lhF a t h e r - E h t
In ordinary family life, the father protects both child and
mother from unduly getting into each other's hair-from
seeming to absorb and annihilate each other to the point of no
PSYCHOTIC CHILDREN
return. He relieves the tension between mother and child. He
keeps within bounds the explosiveness inherent in too close a
union between them. He mediates reality. However, if due to
various circumstances an unduly close union is maintained,
the influence of the father is kept out. If the father is kept out,
mother and child continue to interpenetrate each other.
TAcM& Factor
Much clinical and observation work has demonstrated to
me that the nipple-tongue which reaches out into, and brings
in the outside world, becomes associated with the penis. By
processes I do not understand the hard thrusting nipple-
tongue-penis becomes associated with the father and other
men. At a certain stage in treatment the child becomes aware
of men in the clinic, or uses male dolls in the consulting room to
express his feelings about the hard, thrusting male aspects of
himself and of the outside world from which he is not clearly
differentiated.
An observation of a normal child Sarah aged two years will
now be quoted to illustrate some of the salient features of this
mode of functioning. In the presented piece of observation
Saroh was drowsy. This meant that differentiation between
herself a i d the outside world was much more hazy than usual.
As the focus of her attention waned she became leas organized
and differentiated in her responses. This observation of a
normal speaking child is useful in that it can depict states
which we encounter in non-speaking, psychotic children
whose limited differentiation and lack of psychic organization
is of a more long-standing and rigid kind.
I was helping Sarah to prepare for bed. She wanted 'to do a
wee' and on her way to the bathroom took a boy doll from
her doll's pram. She called it 'MyDenis'. (Denis being the
name of her father.)
On the lavatory she put the doll right up between her
legs and laughed saying, 'My Denis !'
She picked a piece of wool which was hanging down
between the doll's legs and said, 'Pussy got a tail! Doggie
got a tail!'
She then put the doll's head into her mouth and said
'Going to eat Denis. He's in my mouth for always .. .No
onecan have himlme.' (Shegot mixed up with the pronouns
'me' and 'him'.)
She then saw the buttons on my jacket and said,
'Mummy's got buttons', whilst at the same time touching
her own breast. She then tried to pull off my buttons, but
when she couldn't do this she took my handbag and, pulling
out the keys, put these between her legs saying as she did so,
'My daddy thing.' Then rousing herself fiom her sleepiness
and looking at me triumphantly she said, 'Now you're no
good.'
Later when she went back to the sitting-room, she put the
boy doll on her mother's lap saying, 'Mummy can have
Denis.'
DUcussion of Obsmahahon
The above observation was recorded before I trained as a
child psychotherapist. I did not understand it then as
thoroughly as a I feel I have as the years have gone by.
On the edge of sleep, the distinctions which Sarah makes in
her wide-awake state are becoming hazy. Her father and his
bodily appurtenances can be part of her body, as can the but-
tons of a mother. The boundaries between herself and other
people are melting away. Her father as a differentiated person
having arms, legs and head, etc., seems to have become a
'daddy-thing'-a male element which is part of herself. Oral
and phallic elements are relatively undifferentiated and fused
in her experience. Sarah finishes by restoring the father-
element to her mother before she settles down to sleep. This
bodes well for her sleep that night and for her future develop
ment. It is possible that the whole sequence of activity worked
over some of her deep fears about falling asleep.
PSYCHOTIC CHILDREN
In working with child patients I have found that sleeping
difficulties are associated with deep fears concerning the loss
of the nipple from the mouth-penis from between the legs-
father from the family (all these being relatively undifferen-
tiated). This sense of loss brings such feelings of vulnerability
and helplessness that lying awake is a nightmare because of the
terrified and angry thoughts which rush in. A gap-a lack-
a loss (whether real or imaginary) becomes a ho-g and
shameful thing. A seven-year-old girl patient of a very experi-
enced therapist expressed this strikingly. She was a very ill
child with a fantastic command of and feeling for words. After
a holiday break Margaret came saying:
Margaret: Interval. That's a rude word.
Therapist :Why is it a rude word?
Margaret: Because it's lewd. An interlude. A space. Look!
(Opening her legs wide and touching her genitals.) *
The clang-cum-punning which is typical of some of these
children is well illustrated.
These illustrations from the conversation and behaviour of
speaking children have been quoted to help us to understand
sessions with non-speaking psychotic patients who are in a
similar state of functioning. Clincial material from psychotic
patients which illustrates the importance of that which fa&
& m k , I have called the 'male element', will now be pre-
sented. The first piece of clinical material is taken from work
with Toby whose material was used earlier in this chapter.
Non-speaking Toby ran ahead of me into the therapy room
and took the father doll from his open drawer. He lay on the
couch looking at this doll, putting it between his legs and
making no response to me. I felt left out and useless.
After a time he got up and I saw that he had wet himself.
(He is toilet-trained.) He then looked at the taps as if he
I wish to atprau, my thankr to Miss Jeslr Guthrie for permhion to
quote t h i a very intereating piece of clinical material.
were going to turn on the water. (When he first came into
treatment Toby had spent all his time turning on the taps,
filling the bowl with water and letting it out again. I had
stopped this when it seemed to become a perseverating
activity which was getting us nowhere. It had seemed to me
that interpretations about his wrapping himself in Tustin's
water had not been effective because he then proceeded to
wrap himself in my words. After I had stopped the water
activity he took to diving into my couch as into a body.)
After looking at the taps as if he were going to turn on the
water, he desisted. He then came over to me to look at my
watch. He made as if to pull out the winder-knob at the
top of the watch. (This was interpreted as wanting to take
the 'daddy-thing' out of me so that he could do just as he
liked-i.e. stay as long as he liked-wet himself when he
liked-play with the water-make me (my watch) come
to a dead stop.)
Gradually, by other interpretations I tried to help him
to understand that my absence had worried him-he had
felt he had a hole in his body. So now he wanted to take the
'daddy-thing' from me so that he could stick it on himself
and feel that he was boss and could make mc come and go as
he pleased.
At the time of writing, as the result of further clinical

material, we are working on the fact that these attempts to
undermine my authority, to deprive me of the 'fathery-elements
which discipline him, render me no-good and useless to him.
Saddled with this useless mother with no upright father to
support her he cannot grow up properly.
If the outside home situation (or therapeutic situation),
reinforces such an intra-psychic situation, the child is indeed
in trouble. In colloquial terms he feels that he can 'take the
micky' out of his mother and get away with it. This seeming
to take the hard male bit from the mother to make her unduly
soft and malleable and as a protection for himself, brings its
PSYCHOTIC CHILDREN
own downfall, for in his vague state of blurred differentiation,
her loss is his loss also. The following record of a session with
another R.S.A. ( I ) child illustrates this clearly, as well as other
important features of this phase of treatment.
Clinical Matct-ial
Introductory remarks need to be made before presenting
this session. Paul was aged two-and-a-half years when he came
into five-times-a-week psycho-analytic therapy. In the early
sessions he urinated and defaecated anywhere in the room.
Gradually, the therapist established that he used a pot and
almost all the early sessions were taken up with large defaeca-
tions and urinations into this pot. These were seen as attempts
to fill the therapist, and her things, with his bodily products so
that she seemed to be made up by and part of him. Thus,
awareness of separateness from her was kept at bay. At other
times, they seemed to be attempts to fced himself on his own
bodily substances so that he need not admit his infantile depen-
dence on the therapistlmother.
Sometimes he rolled himself up in a rug on the floor. This
was interpreted as wrapping himself in the therapist's things
so that he felt safe from harm. At other times, he rolled strips of
paper or plasticine as if wrapping something in it. This was
interpreted as wrapping up the therapist so that she seemed
part of him.
After a year of treatment, Paul became very pre-occupied
with holes, in particular, the hole in the stairwell which
receded down and down to the bottom floor as he mounted the
stairs. This may have been associated with a sinking feeling in
the pit ofhis stomach from which it was scarcely differentiated.
With this development of a limited ability to bear the fact of
the nurturing person's separateness from him, and also the
associated fear of being 'let down', he became interested in
men in the clinic.
A session will now be presented which demonstrates this and
also Paul's growing awareness of holes. He also demonstrates
to the therapist his autistic attempts to fill these holes. In read-
ing this session it should be remembered that this was a psy-
chotic child and that interpretations concerning his behaviour
which would be correct for a neurotic child are not correct for
his. The key to understanding such material is that the child is
responding to the outside world in terms of his own body,
differentiation between his own body and the outside world
being vague and in a state of flux.
The careful and percipient record of Paul's session will be
given in a slightly edited version. The therapist was Mn Lynn
Barnett. The simplicity and economy of her interpretations are
a good illustration of those to which such a child can respond.
That they affected his behaviour is well demonstrated. Her
critical 'sieving' of the child's material (and also the sug-
gestionsof her supervisor !) ,have been a great help to both of
US.
She writes :
Paul ran to me eagerly. It was a Tuesday session and he was
beginning to notice week-end 'breaks'. He was also noticing
holes, particularly the hole of the stairwell. On the way to
the therapy room we met a young male doctor who had
carried him to the therapy room when he was in an upset
state just before a holiday break. Paul recognized him and
looked pleased. He even seemed as if he might speak. How-
ever, he did not do so.
As we reached the therapy room he eluded my hand
and ran past the open door to another room occupied
by a male worker into whose room he had gone on previous
occasions. When he reached the door he stopped and did
not open it but turned to clutch me in a frightened way. He
then ran back to the therapy room and lay on the couch
clutching his penis.
After a time he got up and went over to the toy box from
which he took an orange felt-tipped pen. He fingered the
tip and with his left hand drew some marks on a piece of
PSYCHOTIC CHILDREN
paper. He repeated this with another pen. He seemed to
find this reassuring.
He then rolled some plasticine into a long snake, touch-
ing his penis as he worked. A bit fell off on to the floor. He
did not cry as on other occasions when this had happened
to him.
Leaving the plasticine Paul came to me. He had his
thumb in his mouth. I interpreted that he felt that his mouth
was a hole he had to fill. In direct response to this inter-
pretation he put his finger into the outlet hole in the sink,
turning so that I could see what he was doing. After this, he
came and sat on my lap.
After a few minutes he left my lap and turned on the
water tap watching the water run down the sink hole.
Suddenlyhe went across the room and drew the curtains.
After he had drawn back the curtains he went to the sink
where he picked up the plug and looked at it c a d d y . He
put it to his ear, his mouth and then the plug hole. The tap
was still running and now that the plug was in, the sink
filled with water. He became very excited, and made
'Ooh !' 'Ooh !' noises and excited up and down movements
with his body and head.
He made an 0 with his forefinger and thumb and let the
water from the tap run through it. He then put the tips of
his fingers into his mouth, looking at me whilst he did so.
He then delicately put his fingers into the circular bubbles
on the surface of the water. Finally, he climbed on to the
side of the sink so that he could get his whole mouth into the
water. Pad smiled when I linked the plug hole, his mouth,
the finger circle and the bubbles with the suggestion that he
wanted to fill up holes as he was trying to suck water into his
mouth.
When I said that it was time to finish Paul picked up the
metal waste-paper bin and put it into the sink (as if it
were an open mouth).
Clinical DUcussion
For those of us who have been trained to work with neurotic
children it is tempting to interpret such material in terms of a
classical oedipus complex, interest in the anatomical differ-
ences between boys and girls, and classical castration anxiety.
However, further consideration shows that this would be
inappropriate.
The psychologist had tested Paul a month before this session
occurred and had found that he was still 'a-symbolic'. The
neurotic processes cited above are dependent upon capacities
for symbol-formation, for fantasying and for observing the
outside world as separate fiom the self. None of these processes
were possible for Paul, although we see the elements from
which they could develop. The making of analogies between
objects in terms of shape can be a basis for later symbol-forma-
tion. Making a circle with his thumb and finger, and putting
his finger into the outlet hole of the sink seems to be a primitive
form of representation: By an action he makes a model of a
situation about which he wants to communicate. Also it is
idonal communication rather than reactive reactions such
as defaecation, screaming and tantrums. But his capacity to
communicate and his cognitive functioning are still on a rudi-
mentary level.
It is true that in children of Paul's age (and also Sarah,
Toby and Margaret), the facts of the outside world such as
boys having penises and girls having holes have almost cer-
tainly been drawn into a blurred awareness of the outside
world. But this outside world is primarily interpreted in terms
of bodily sensations. This is very different from using outside
situations which seem analogous to inner emotional states to
express and communicate about them, which is the essence of
fantasy. The capacity to fantasy is associated with symbol-
formation, and needs a considerable awareness of separateness
from the outside world, with awareness of outsides and insides,
and of being a self with an inner world. E.S.A. and R.S.A.(x)
PSYCHOTIC CHILDREN
children have little or no inner world. Their limited degree of
differentiation makes this impossible.
As we have seen, the psychotic child lives predominantly
in a world of black and seething matter pitted with voids which
lack any principle of organization. This is very different from
the world of the neurotic child. The psychotic child has de-
veloped protective reactions (pathological autism), to safe-
guard bodily survival. These are very different h m the
organized defence mechanisms of the neurotic (such as split-
ting, projection (in its usual sense), repression and denial),
which have developed to protect the psyche from unbearable
mental pain and distress. It seems to me that codhion is often
caused by the discussion of psychotic states with the use of
terminology evolved for the description of neurotic processes.
In the light of the above comments, Pal's session will now

be considered and suggestions made concerning possible
understandings. In eluding the therapist's hand, Paul may
have felt he made her into a 'softie', her hard male element
being by-passed and seen elsewhere. In doing this, he cannot
bring together the soft 'mother' elements with the hard 'father'
elements. There is no good connection between them. Breast
and nipple are not felt to be in a good working combination.
This increases his sense of lack, of having a hole. This has pro-
voked him into trying to get more than is provided for him
(another room-another person). Like Sarah, he tries to cap-
ture the clinic mother's 'man' for himself as part of his body to
make him feel held together and complete. But since he is only
tenuously differentiated from the clinic mother, the loss of her
male element is his loss also. Encircling his penis with his hand
makes him feel that the thrusting 'male' element is safely
within the receptive 'female' element-the 'button' is in the
'button-holey-he is 'all-buttoned up'. He is safe. But he has
done it for himself and has not used the linking possibilities
in the outside world.
Thistrying to get the male bit out of the clinic mother means
that he feels possessed by a mother with a hole which is
repeated in his own body. He is driven to try to fill her holes as
well as his own but this is far beyond him. In this session, faced
with this super-human task, we see his attempts to deal with
the holes by which he feels surrounded. He seeks reassurance
by touching the points of the pencils, he tries to make a plasti-
cine 'snake', he feels his own penis, he put his thumb in his
mouth, he plugs up other similar holes, he sits on the therapist's
lap, he draws the curtains over the window (this may have
been an attempt to cover up a vulnerable part of the room,
just as his eyes-'the windows of the soul'-are vulnerable
parts of his body); he makes excited movements with his
body and head and finally fills the hole of the sink with the
waste-paper bin. In short, Paul is experiencing psychotic
dep'ession and all that this implies, and is showing his autistic
attempts to deal with it, that is, he blocks up those parts
of himself and of the room which give access to the outside
world.
As the treatment progresses and the child eventually finds
that the hole cannot be plugged in this materialistic way, he
may cry and scream, often for hours on end, in a most distress-
ing way. The therapist and anxious parents have to bear a
great deal of despair before sustained reciprocal relationships
with caring people develop, and before he uses things in the
outside world properly instead of 'mucking about with them'.
As reciprocal relationships develop the terror of the 'hole' and
all that this implies, become mitigated. Progress to this stage of
treatment comes as the child becomes able to bear frustration,
although he often kicks against it. The therapist has to stand
firm against these outbursts.
In this type of psychotherapeutic treatment, frustration
comes as part of an organic process developing between child
and therapist and not as an artificial, isolated piece ofmanipul-
ation. Non-tolerance of fmtration is a critical part of the
child's illness: Thwarting needs to come from someone who
PSYCHOTIC CHILDREN
knows him well having lived through a great deal of thwarting
from him.
It is important to remember that these children have felt
hurt at a tender age in a particularly tender spot. They need to
become able to accept tenderness from caring people if the run-
ning sore scabbed over by the autism is to be healed. In their
cosy huddle with themselves, or with their mother, they have
established a taboo on tenderness, even though many parents
of these children are able and willing to give it. In their autistic
state, these children do not call forth tenderness. In my own
experience they provoke seductiveness and cruelty. There are
desperate feelingsofwanting to batter down their unrewarding
child's resistance. Also, it is no good trying to force ordinary
loving care upon them. They either become invasively 'sloppy'
or freeze in terror.
The therapist's aim is to disturb the child's autistic system
just sufficiently to allow outside influences to percolate, so that
the outer encirclement provided by the therapeutic settingand
the therapist's work and concern can become an inner illusion
of nipple-encircled-by-mouth-the button can seem to link
with the button-hole. To put it another way, a marriage
between the male and female aspects of their personality
begins to take place. These are felt to pull together rather than
to fall apart. (The actual facts of the outside world can reinforce
or hamper this.) The paradox is that for this 'buttoning-up' to
occur, it is necessary to become able to bear vulnerability,
muddle, ignorance and disorganization. Therapy in this first
phase is a subtle and delicate task which requires sensitivity,
imagination, common-sense and dedication on the part of
the therapist whose own internal 'marriage' needs to be firm.
Therapist and child have to learn that sensitive vulnerable
areas can be rewarding points of contact rather than places
where frustrating, mutilating disconnections seem to have
taken place. To be invulnerable means to be incommunicado :
Not to communicate preserves invulnerability. But at what a
cost !
PHASE2
In this phase the child begins to live in his own mind. But
living in one's mind brings distressing limitations. At first,
hallucinations and later, dreams and fantasies help to relieve
the strain.
Hallucinations
As the child becomes more intact he begins to have hallucin-
ations. The therapist may be some time before he realizes what
is happening. I would agree with Roderigues that the visual
hallucinations are a sign of progress and help in establishing a
closer relationship with the child. Sometimes these hallucina-
tions are persecutory ones, like John's 'birds' which 'mobbed'
and threatened to peck him. These seemed to be flying rival
mouths. At first, these hallucinations may occur away fi-om
the treatment setting and become a great source of worry to
the parents who fear that the treatment is causing their child
to be 'out of his mind'. Which, ofcourse, he is. But, as the fright-
ening hallucinations are brought within the orbit of the treat-
ment setting, they can be brought within the child's mind and
under rational control.
At some point, during this stage, the child oRen becomes
afraid of his own shadow. This 'shadow' seems to be explo-
sively-projected, physically-experienced rage, an enormous
defaecation which threatens and burdens him. I t is a kind of
'dirty nappy' of which he cannot rid himself. As he allows
cleansing and reciprocal relationships to become more and
more a feature of his behaviour, the fear of his shadow dimin-
ishes.
In the treatment setting benign hallucinations occur. These
are of absent people. Invariably they are members of his own
family. This is partly to feel that home and therapy are in the
same place so that there is no time when the therapist is away
or family figures are away, that is, it is a magical attempt to
deal with the situation of absent people and to bridge the gap
PSYCHOTIC CHILDREN
between them. Associated with the situation of absence, these
hallucinations have another significance. Hallucinating seems
to be an omnipotent forerunnerof 'remembering' or 'calling to
mind' an absent person. Hallucinations seem to have the sig-
nificance of creating someone, of making someone appear, not
only in the mind (asremembering does) but, in the unbounded
fashion of omnipotent functioning, in the outside world also,
much as the genii appears in fairy stories. In these omnipotent
states, to 'see' a thing is to create it, like the Berkleyan 'tree in
the quad', when viewed 'by yours faithfully God'.
The negative hallucination seems to be the omnipotent fore-
runner to 'forgetting' or 'ignoring'. I t seems to have the mani-
fold significance of dropping somethingout of the mind (much
as a faecal stool is dropped out of the anus), or obliterating and
burying it with body stuff turgid with such omnipotently
murderous and suicidal rage that it is a madness which cannot
be contained within the mind. Not to look, not to listen, not to
use, is to deny the existence of an object, to obliterate its
'being'. As we have seen, the autistic child attempts to obliter-
ate the source of the trauma by blacking out 'not-me' objects.
Such 'blacking out' would seem to be one source of amnesia.
At these levels, neglect and lack of attention is experienced as
existence being denied, 'being' being obliterated. Ignorance
results from ignoring.
Interpretations concerning hallucinations seem to enable
the child to withdraw these images from the outside world to
manipulate them within his own mind as mental images. The
play ofideas in the mind has begun. He also begins to play with
the t o p in the treatment situation in a much more consecutive
way. This omnipotent creation of absent objects by hallucina-
tion would seem to be the forerunner of 'imagining', 'remem-
bering', 'thinking'. Viewed in this way, hallucinations are a
step on the way to recovery and not a disturbingpathology.
CognitiveDm~lopmmt
The core of W. R. Bion's work on 'thinking' is that toleration
of the frustration of the absent breast is crucial to forming a
mental image of it, and that this sets mental activity in train.
As he expresses it (1962, p. 37), mental activity begins when:
..
'. the wanted breast is felt as "an idea of a breast missing"
and not as a bad breast present.'
De Monchaux ( I962, p. 314) commenting on Bion's work
..
writes :'Bion's approach is. subtle. The "no-breast" thought
is a more highly adaptive piece of mental work than the "good
breast image".'
OYShaughnessy(1964, p. 34) points out that the 'no-breast'
situation 'By its harshness ... forces reality on the child, and
breaks the hold on phantasies which protect him from realiza-
tion of his vulnerability and dependence. I t makes him know
reality.' But for various reasons, the E.S.A. child has encoun-
tered this situation too soon. The child needs to have had, and
to h u e wed, sufficient 'good breast' experiences if he is to toler-
ate the 'no-breast'. I would think that when the child begins to
have benign visual hallucinations in therapy he is drawing on
his store of 'good breast' (good family) experienca. But, before
he can fully tolerate the 'no-breast', persecutory hallucinations
have to be brought within the scope of the therapeutic setting
to be tolerated and modified there.
This has been discussed in detail because if the child
becomes responsive, the next most difficult part of therapy is to
help him to use his wits. His mental functions, which are little
differentiated from bodily parts, seem to have to have become
broken and out'ofjoint. To protect them, in the E.S.A. child,
encapsulation has taken place. This means that each function
is felt to be discrete and separated from every other so that we
get a situation such as Rimland (1962,p. 79) describes when:
'The vital connections between sensations and memory can be
made only with difficulty.'
In this situation, one function may shoot ahead quite out of
touch with the others, resulting in the so-called 'idiot-savant'.
As the child becomes more accessible, and encrusted encap-
sulations ('secondskim') are abandoned, the healing of the
PSYCHOTIC CHILDREN
disjointed and cracked functions becomes possible. (The child
is no longer a 'crack pot' from whom bodily-cum-mental bits
can drop so that he is 'out of his mind'.) Thus, the next stage is
when the child, as it seems, ~uddmlygets the notion that he can
m~ndthings, albeit omnipotently. As he feels that he can mend
the 'holes' and 'breaks' which seem to be in his own body,
he gets a more secure sense of bodily and mental integrity,
and thus of personal identity. In John, the patient cited in
Chapter Two, this was strikingly illustrated when his first
use of the personal pronoun came apropos a toy bus he had
broken in a tantrum, of which he said, 'I mend it! I mend
it!'
The next stage is reached when the patient gets the notion
that I, as a therapist, can mend him. Again there is omnipo-
tence in this, in that I am endowed with superhuman powers,
but omnipotence is diminished in that he begins to bear being
dependent upon an outside person. A certain degree of trust
has developed. This healing that the therapist is able to do is
sometimes associated with oil as a healing medium. David, of
Chapter Three oiled his dinky cars like a high priest giving
divine unction. At times he felt that I did the same for him.
Winnicott (1958)cites two adult psychotic patients with whom
this was the case. One of them speaks of oil 'as the medium in
which the wheels can start to move'. Winnicott then goes on to
say that this was an important forward step in the man's
treatment, because he had come to the notion of the analytic
situation being a healing and facilitating medium which held
him. This development of trust in the therapeutic 'holding
situation' is an important step, but it brings with it all the
anxietiesconcerning dependence and separateness.
In this phase, when the child is beginning to be able to bear
the awareness of a clear distinction between himself and other
people, there invariably develops a fantasy which I have come
to call the 'nest of babies' fantasy. This is associated with the
notion that there are 'special babies' who are given 'special
food'. (John called it 'eggda'.) My 'brain children', the
children in my mind whom I am felt to feed when I am pre-
occupied and averted from him, are sometimes felt to be the
recipients of this special food. There is the fantasy that he (the
patient-the child who is receiving my therapeutic milk) is in
competition with predatory rivals on the other side of the
'breast' who want to snatch the nipple away from him-to
take away his chance of life and sustenance. At times, in
terror, he avoids feeling dependent on another body and turns
to his own. The faeces in his anus are felt to be a kind of walking
larder, his own private breast. Or his spit is felt to be 'the most
delicious liquid that there is' (Bonnard 1960, p. 302). These
fantasies.about especially favoured babies who are given
special food were also characteristic of an anorexia mmosa
patient described by the author (Tustin 1958). At this stage,
the eating idiosyncrasies which are often characteristic of
autistic children begin to assume prominence at home and may
be given up. The child also begins to learn, that is, to take intel-
lectual food.
The 'nest of babies' fantasy is the earliest feature of the stage
when the child clearly begins to have a mind of his own. In this
fantasy the child is concerned with getting all he wants. The
state is imagined and therefore he feels that it exists. But, as
reality creeps in, he realizes that it does not. The next thought
is, 'But there are some who have itY,to be followed by, 'But it
isn't me'. This leads to disappointment, rage, jealousy, envy
and competition, all in terms ofimaginary especially favoured
entities. The early forerunner to all this was the disappoint-
ment that the climax to his oral-cum-sexual excitements was
not always forthcoming from the outside world in the exact
terms of his overstimulated expectations-the world was not
body stuff to be moulded in his own terms. Thus, in therapy it
is not necessary to give him oral satisfactions but to help him to
bear the feelings associated with finding that the outside world
is not continuous with and part of him but can change and
disappear. In doing this, the acceptance of his panic, grief and
rage as natural feelings which can be patterned in terms of
PSYCHOTIC CHILDREN
thought and speech, rather than being formless, threatening,
black, impossible-to-comprehend masses, is an important part
of the therapy.
For various reasons, these children have encountered too
soon the notions of rivalry which seem to be associated with
awareness of bodily separateness. In times of want, the child
seems to feel that other rivalrous mouths are enjoying what he
lacks. Autistic children seem to have been pressed or to have
attempted to do too much, too soon for them. As well as this,
they may have had a depressed or unduly introverted mother
who tended to undervalue herself. As well as being handled in
a somewhat undercoddent way, they seem to have had the
feeling of being in violent competition with other rivals for
their mental satisfactions. They seem to feel in rivalry with
their mother's thoughts, as if they were her brain children, for
aftmtion which seems like mental sustenance. In despair, the
child places undue emphasis on the physical link with the
mother (the 'button') and on bodily modes ofcommunication,
since the more normal mental ones seem to be unforthcoming
or unavailing, since he is unable to use them. Thus, the thera-
pists' attention, her thinking as expressed by her behaviour, her
comments and her interpretations are the most important part
of the therapy. Methods which unduly emphasize the giving of
physical satisfactions by the therapist reinforce the child's
pitiful fallacy and underestimate the importance of under-
standing.
As we have seen, the startled 'jump' ofpanic and rage meant
that several developmental phases were precipitated at the
same time one on top of the other; developmentgot out of joint
and became impacted. Thus, therapy consists of sorting out
stages of development and allowing the child to go through
them at a more normal rate. Precipitate, terrified impulsive-
ness is kept in check.
However, as fears are focused and differentiations proceed,
the child begins to feel that in his inner world there is a superla-
tively beneficent 'button' presiding over a superlatively happy
'breast of babies', whilst in the shadows there lurks a 'black
hole' containing threatening, cruel, demon-like entities. The
latter being a source ofparanoid fears. It seems important that
this 'not-me' 'black hole' should not be by-passed, for when
focused and modified, the network of paranoid fears associated
with it seems to be significant in sieving the outside world, so
that receptiveness is not unduly undiscriminating and global.
However, at this stage of therapy, as well as seeing the begin-
nings of mental functioning, we seem to come upon the main-
spring of morality. This was well illustrated by the little girl
whose 'black hole mummy', whom she greatly feared, became
a strict policeman as she grew up.
At this stage, the parents often break off treatment. The
child has now become sociable and teachable and they feel
that they can help him themselves without therapeutic inter-
vention. I sympathize with their feelings, for here is a child
who has been inaccessible for years and who is now able to
respond to their overtures. I t is understandable that they want
to enjoy him without sharing him with a therapist. However, if
he can remain in treatment, his growing realization that
therapy is a joint piece of work between himself and the thera-
pist will mean that omnipotence becomes diminished and the
gains from treatment can become more stable.
Conclusion
Psychotherapy with psychotic children needs a whole book
to do it justice. The foregoing account may seem unduly con-
densed in parts especially to those workers who are not psycho-
therapists. However, it has seemed important to describe some
of the psychotherapeutic sequences which have occurred in
treatments with a reasonably satisfactory outcome. Some older
children who, without treatment, would have needed institu-
tional care for the rest of their lives, have been enabled to live
at home and hold down unskilled jobs in the community.
Those children who began treatment when they were two or
three years old have been enabled to live a relatively normal
PSYCHOTIC CHILDREN
life, although they were somewhat over-sensitive individuals.
In certain quarters psychotherapeutic treatment has fallen
into disrepute; it is hoped that this account may help to modify
these attitudes.
CONCLUSION
T H I Sbook has been concerned to describe certain aspects of
childhood psychosis which have attracted the attention of one
child psychotherapist and which do not seem to have been
dealt with elsewhere in any detail. It has been difficult to
write about such intense states of raw feeling. Wherever pos-
sible homely language has been used to offset their strangeness
and to link them with elemental experiences embedded in the
idioms ofour language. Evocative language has also been used
to enable the reader to enter the strange world of psychotic
children. Total immersion and the ability to emerge from this
immersion with a deeper understanding of oneself and the
child is the only effective way of helping them. For some
readen this must have seemed like a baptism by fire.
However, the thesis that has been developed is an ordinary
though fundamental one. It has concerned the building of an
inner construct of reality which is sufficiently akin to the one
that is commonly agreed to facilitate communication by nor-
mal means. In the normal autism of early infancy there are the
components from which this can take place but which are not
developed. In 'total' pathological autism there has been such a
profound arrest or regression that the building of this inner
construct has been impeded or impaired so that the child is
completely out of touch with the outside world and with
people. Reaction to the outside world and people is in terms of
bodily functions, organs and zones.
At some point, that which, in retrospect, was felt to be an
endless flow of body stuff seemed to come to a foul and violent
end. Routines associated with the mouth seem to have catas-
trophically broken down. Without sufficient support in bear-
ing this the ensuing state becomes a morbid one. Everything
had seemed to be promised, yet all had become nullity. Bound-
lessness had become acute restriction. Sublime self-fulfilment
had become a hole. Nomlprimary a r c h had become the lunar
CONCLUSION
wastes and craters of pathological secondary atism. The craters
ofpsyhotic dcp'ession both inhibit development, and precipitate
pseudo-development out-of-phase in an uncontrolled and
unruly fashion. Thus, development may be in 'islands' or be
inhibited or be impacted or go along avery restricted avenue of
one particular talent or be regressed and disintegrated.
A classificationof psychotic illness has been suggested which
takes into account psychotherapeutic treatment possibilities.
In addition, it has been suggested that in certain neurotic ill-
nesses there is a part of the personality in which autism still per-
sists. Autistic encapsulation also seems to operate in an overall
fashion in a certain type of character structure in which denial
and global functioningplay a predominant part.
It has also been suggested that 'normal' individuals may
have deep-seated vestiges of autistic functioning. This can be a
source of weakness or of strength. I t may manifest itself as an
eccentric, individualist tendency to reject commonly accepted
ways of looking at the world. Fear of it can lead to undue con-
formity or to over-ambitious mediocrity. Properly used it can
lead to originality, creativity and independence. Viewed in
this way, the study of pathological autism has relevance far
beyond the study of a severe psycho-pathology.
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INDEX
By Lilian Rubin, M.A.
Note: An asterisk denotes a mention in the list of References.

Names in italics refer to children whose behaviour is discussed.
abnormal primary autism anxiety -see Fright, fear and

(A.P.A.) 69-75 anxiety
comparison with E.S.A. and Appell, Genevieve 70, 108
'armour*-see David; Tessa
~ ~
R.S.A. (q.v.) 85-88

differential features (Chart 'as if '
11) 96101 behaviour 59
distinction between people oedipus complex 116
and things 79 personality 54. 123
gross lack of essential 'atmospheric' children 10.
nurturing 70-7 1 34
impediments in the child attention
73-75 paid to infant 26-27, 103
partial lack of essential of therapist 175
nurturing 7 1-73 autism, concept
precipitating factors (Chart normal compared with
11) 92-95 abnormal 1-2. 103.
as prolongation of primary 105
autism 92.96 autism. normal -see Normal
Tom 72-73 primary autism
treatments prospects 108- autism, pathological;
110 Pathological autism.
acting out, in therapy 123 See also Abnormal
alienation 105 primary autism;
amnesia 171 Encapsulated
'amoeboid' type of child 49- secondary autism;
50.73 Regression to
animals, in clinical material secondary autism
42.43 autism, syndromes 124-138
animism 79 See also Childhood
anorexia nervosa 8 1, 174 schizophrenia; Early
*Anthony. J. 92.104 infantile autism
autism, types compared 85-89 nameless dread 27.130
factors, precipitating (Chart psychological catastrophe
1) 92-95 8
features, differential (Chart reverie 25.55, 108
XI) 96101 on thinking 171-172
autistic barriers 78, 103-108 bisexuality 114-117
autistic objects 6 0 6 8 See also Male factor
abnormal 66 Bion, 'bizarre object'
distinguished from 'black hole'
transitional 62-63.68 felt reciprocally by mother
function 79 and infant 26
in pockets of encapsulation Johns' experience of 13-14,
81 1617.18-19.22-24.
Matthew 64-65 27
Philippa 62-63 significance of 22-24
Sarah 66-67 as source of paranoid fears
Susan 60-62 176
autistic processes *Bleuler, E. 85, 102
described (David) 3 2 4 2 blindness 73-74
discussed 42-50.55-59.75 bodily movement and
coordination 88, 120-
backward pull, of vestigial 121, 127
autism 84 See also Physical
Bacon, Sir Francis 144 development
*Balint, M. 8
Barnett, Lynn 164 *Bonnard, Augusta 112, 174
barriers -see Autistic barriers *Bowlby, J. 49.69
'basic fault' (Balint) 8 'brainchildren' 141-142, 173-
Bender, L. 136 175
benign hallucinations 170, 172 brain dnmage 73-74
*Benjamin. J. D. 5 1 breast
*Bergman, P. and Escalona, S. experiences - see John
24.48, 129 image of, in cognitive
*Bettelheim, B. 44 development 172
Beyond the Pleasitre Principle See also Black hole; Button;
(Freud) 75.84 Nipple-tongue
*Bick. E. 53-54.57 combination
*Bion. W. R. - 'breast of babies' 173-174, 180
Acknowledgements bridges (reciprocal response)
on bizarre object 119 154-156
critical point of bristling, with rage 43, 59
development 24 *Brodey, W. M. 87
INDEX
'button' *Creak. M. 102.124. 134
development of 'critical hurt' (Jungian) 8
communication 27-30 'crustacean' type of child 49-
felt as beneficent 175- 176 50.75
significance of 20-22 cumulation of frustration 58-
See also John 59
Burke, on privation 7 1 David
the 'amour' (Fig. 3a & 3
care of psychotic children 83, b) 4142.4347.52,
150-152 54
childhood schizophrenia autistic barrier 104-106
(syndrome) 121- 126. case material
136144 presented 3 2 4 2
clinical description (Ralph) discussed 42-50
139-144 dinky car used as autistic
differential features (Chart object 67
nr) 136-138 grit sensations 36. 3 7 4 0 ,
distinguished from early 43.51.65-66
infantile autism 124- the 'monster' (Fig. 2) 35-
125,134 41,4244
fantasies and breakdown 85 oil 173
classification of 'nice' and separation experience 32-
'nasty' 15.23 33.48
classification of psychotic Day. Beryl 66
children 102-123, deafness 73-74
124-126 death instinct (Freud) 84
See also Diagnosis defence
cognitive development 87, inhibition as 75.92
171-176 regression as 92
communication delinquency 8 1
autistic barriers 107 delusions, distinguished from
construct of reality 178 illusion 46
prior to speech 157-158 See also Hallucinations
sense of identity 27-30.57 De Monchaux. Cccily 172
therapeutic 146-149 denial 8 1
compulsion-repetition 77 depression - see Mothers;
constitutional and genetic Psychotic depression
factors 24.73-74.76, despair 27. 107, 168
133-135 *Deutsch. Helene 54. 122
continuity -see Illusion of diagnosis, of psychotic
continuity children 85, 122-123
cradle 30 See also Classification
differential features syndrome associated with
of types of autism (Chart Il) E.S.A. 85, 124
96-101 echolalia 44.64.87, 127
of early infantile autism and ecstatic sensations 58,8142,
childhood 154
schizophrenia (Chart embryonic self 55
111) 136-138 -
empathic identification see
differentiation Reverie
between people and things encapsulated secondary autism
57.79 (E.S.A.) 75-84
'patchy' 71-73 autistic barriers 105-106,
disintegration, in R.S.A. 85. 107
119-121 bisexuality 114-1 17
disturbance in utero 48 cognition 172-176
diversionary sensations 66 comparison with A.P.A. and
dreams & nightmnre 12, 14, R.S.A. (q.v.) 85-88
16.58 'crustsiceans' 49-50
See also Hallucinations differential features (Chart
11) 96-101
E.S.A. -see Encapsulated distinction between people
second'uy autism and things 79
early infancy. normal autism of eiuly arrest of development
1-2 96
early childhood autism (Wing) encapsulation processes
-see Early infantile 117-1 18
autism envy and jealousy 144
early infantile autism fits in children 113
(syndrome) 124-138 inhibition, as defence 92
bodily movements 88. 127 lack of inner life 112-1 13,
compared with childhood 166-167
schizophrenia 124- physical development 117
125, 134 'pocketed' processes 81-82
differential features (Chart precipitating factors (Chart
111) 136-138 I)92-95
etiology 128-135 rage 113
genetic factors 133-134 survival 113-1 14
intelligence factor 128- the tongue 112-1 13
130 treatment prospects 110-1 19
John 4 See also John; David
Kanner on 1 encapsulation. in R.S.A. 88-89
mothers 130-133 environmental circumstances
Rimland on 85 76
INDEX
envy 122,125.143-144. 174 frustration
explosive projection cumulation o f 58-59
(eruptions) 24.26.47- felt as tangible discomfort
49.58 59.65
explosive violence, of in therapy 168-169
psychotic children 145 See also Grit sensations
eyes
comparison o f R.S.A. and genetic factors -see
E.S.A. children 88 Constitutional and
David 37-40 genetic factors
in early infantile autism 127 gestalt 57.59.67
and envy 144 global functioning in character
Ralph 140 structure 82-83, 179
as 'windows o f the soul' 'good' babies 84, 110, 139,
168 142
'good enough' mothering
'falling infinitely' (Winnicott) (Winnicott) 75
51.70 Grief (film by R. Spitz) 70
'false self' (Winnicott) 54 grief and mourning, of infant 4.
fanaticism 82 20.27
See also Global functioning grit sensations 36. 3740.43.
fantasy 84-85. 104. 166.173- 51.65-66
174 gross lack of essential
fathers of autistic children nurturing 70-7 1
husband-wife support 76-77 *Guthrie. Jess 161
John's father 11-12.27
a s mediating agents 158- hallucinations
159 benign 17&171, 172
role in treatment 15 1 negative hallucination 104
See also Bisexuality; Male See also Dreams a n d
factor nightmare; John
fear - see Fright, fear and hands
anxiety; Panic, terror used a s autistic objects 68
and rage experienced a s mouths 3 6
first-born males 130 37.57.66
fits, in E.S.A. children 113 hard mechanical objects 67-
*Freud. S. 32.7.5-76.84 68
fright. fear and anxiety (as Hartley. L. P. 48
distinguished by *Hayman, A. 25
Freud) 75 heartbreak
See also Panic, terror and in creative endeavour 83
rage and heartbeats 79-80
helplessness, sense o f 23.25, the 'black hole' 13-14, 16-
158 17.18-19.22-24.27
Herman 138 bodily confusions 21-22.23
*Hoffer, W. 57 breast experiences 12-14,
holding situation 15-16, 19.24
autistic 67 the 'button' 11-14, 16-17,
doll and cot 158 18-19.20-22.274
lack of, with institution case material presented 5-
infants 7 1 18.30-31
primary 25-27 discussed 18-30
Winnicott on 55 drawing by (Fig. 1) 30-3 1
hole - see Black hole early infantile autism 127
hypersensitivity of infant 48. end of treatment 18
76, 128. 129 experience of grief 18-20
father of 11-12.27
'idiots savants' 128. 172 first words, 'gone'.
illness in infancy 48 'broken', 'oh dear!' 9-
illusion of continuity 21.25- 10. 11. 18.24
27.57.66 hallucination of birds 14,
impediments, in children 73- 17, 170
75 mother's difficulties 6-7.25
infant observation 56,6042 nest of babies fantasy 173-
innate forms 21, 104 174
inner life 112-113. 166167 panic 16
institution infants 70-71 progress and setback 14-1 5
integration, conditions for 55 pronoun use 8, 11.30, 173
intelligence. high innate screaming 12. 14-15. 17-
a s factor in autism 76. 126, 18.19
128-130 toys 157-158
in mothers 130-133 treatment setting 7. 30,
intent, inapplicability of tumultuous feeling 65
concept to autism words experienced by 22
47 Judy 74
interpretative procedure 7-8. Jung. C. G. 104
146-149.157, 171 Jungian analysts 8
See also Treatment setting
*Isakower phenomenon 5 1 *Knnner. L. 1.24. 102. 124-
125, 130-131
jealousy -see Envy and *Klein. Melanie
jealousy Melanie Klein Trust -
John Acknowledgements
autistic barrier 106-107 method 8, 145
INDEX
on 'projective Melanie Klein Trust -
identification' 86, 138 Acknowledgements
on 'unconscious phantasy' *Meltzer, D. 24-25, 125-126,
104 144
Kretschmer's cyclothymes 13 1, mending & healing 11.30.
132 173
mental defect 73-74. 109
lack o f inner life 112-1 13. mentally subnormal children
166167 109
*Laing, R. D. 80 *Milner. M. 25
language -see Monchaux, Cecily d e 172
Communication; Moniqrre (film by G. Appell)
Speech; Verbal 70, 108.
difficulties; Words 'monster' - see David
learning difficulties 81 morality, mainspring o f 176
Leigh. Dr. S. - mothers of autistic children
Acknowledgements attitudes to treatment 150
limp musculature 73 depression of 24,7&77,
Lindsay, Dr. Mary - 127, 131-133.174
Acknowledgements 'patchy' differentiation
linking, inner sense of 55.58 illustrated 7 1-73
*Little, Margaret 48 suffering of 80-8 1
in syndrome of early
*Mahler, M,ugaret infantile autism 130-
on: grief and mourning 4 133
mother-child relation 24 'telepathic' communication
panic and rage 23 148
post-partum depression tnother-child relationships
25 in early infancy 24-27
symbiotic love object 8, comparison by types of
20.87 autism 87
vulnerability of autistic mouth
children 47 bisexuality related t o 114-
male factor 159-169 117
See also Bisexuality hands experienced a s 36-37,
Manolson, Mrs. 64 57
marasmitic stntes 70 See also N i p p l e t o n g u e
Margaret 161 combination
Matthew mutism
(in example of autistic E.S.A. children 87
object) 6 4 4 5 early infantile autism 127
(in example of blindness) 74 - in pockets o f autism 8 1
mutism (continued) nurturing
Rimland on 146 austistic barriers to 103-104
Toby 154 essential ingredients in
infancy 69
N.P.A. -see Normal primary facilitating conditions for
autism development 2
'nameless dread' (Bion) 27, impediments 73-75
130 lack of 69-75
negative hallucination 104 rigid or inconsistent 75
nest of babies fantasy 173-174
neurotics observation of normal infants
pockets of pathological 56,6062
autism 81. 123, 179 oedipus complex, pathological
terminology inappropriate to 116
autism 167 *O'Gorman. G. 134
'nice' and 'nasty' as prinisuy oil, as healing medium 173
classification 15.23 *O'Shaughnessy. E. 40. 172
nightmare - see Dreams &
nightmare panic. terror and rage
nipple-seeking pattern 21.23 E.S.A. children 113
nippl-tongue combination encapsulation as defence 75
association with penis 159 on experience of
as cluster of experiences separateness 16.23.
in situations of insecure 49
nurture 79 filling gap between mother
as source of button illusion & infant 58
20-2 1 John 23-24
See also Mouth primitive terrors 158
normal primary autis~n 'salting' of, in normal
(N.P.A.) development 80
differential features (Chart in treatment 145. 175
11) 9 6 1 0 1 paranoid fears 176
difficulties of description parental nurturing -see
55-56 Nurturing
distinguished from parents
pathological 1-2. 103, effect on holding situation
105 27
neo-natal solipsism 92. 96 role in treatment 149-15 1.
precipitating factors (Chart 176
I)92-95 See also Fathers; Mothers
processes described 56-59 partial lack of essential
'nuclear hurt' (Jungian term) 8 nurturing 71-73
INDEX
pathological autism male factor 159-169
distinguished from pre-speech communication
normal 2, 103, 105 157-158
giving insight into normal primitive terrors 158
autism 55-56 Philippa 62-63
principal systems 69-101 phobias 8 1
see Abnormal primary physical development
autism (A.P.A.); R.S.A. and E.S.A. children
Encapsulated compared 117
secondary autism See also Bodily co-
(E.S.A.); Regression ordination
to secondary autism physical maltreatment of child
(R.S.A.) 95
See also Normal primary *Piaget, J. 2 1
autism (N.P.A.) pockets of pathological autism
syndromes 124-138 81. 123
see Childhood post-partum depression 25
schizophrenia; Early Pmtt, Janet, 121
infantile autism precipitating factors, in types
vestigial, in normal of autism (Chart I)
individuals 83-84. 179 92-95
pathological secondary autism presentation problems, with
59 psychotic material 33-
pattern & form, recognition of 34
128. 129 pre-speech cotnmunication
patterns of bchaviour, in 157-158
psychotic children 78- pre-thinking and anti-thinking
81 2
Paul 163-1 68 prickling with fear 43.59
penis 159 'primal cavity' (Spitz) 57, 112
See also Bisexunlity; Male primal depression - see
factor Psychotic depression
Peter 110-111, 119 primary autism - see
phases in psychotherapy 153- Abnormal primary
177 autism (A.P.A.);
phase 1: 153-169 Normal primary
phase 2: 170-178 autism (N.P.A.)
the bridge 154-156 primary narcissism 2
cognitive development 17 1- private language, of E.S.A.
176 children 87
father element 158 'privation' (Winnicott) 7 1.
hallucinations 170-17 1 108-109
prodding, child's reaction from precipitating factors 142-
59 143
projection - see explosive *Rank. Beata 23.86. 118
projection *Rank. B. & McNaughton. D.
'projective identification' 23.24
(Klein) 8 6 8 7 *Rank. 0. & Putnam, J. J. 4
pronoun use reactive depression 4
in early infantile autism 127 reciprocal response (the
John 8, 11.30, 173 bridge) 154-156
Tessa 53 recovery
'psychological hallucinations 171
catastrophe'(Bion) 8 jealousy 144
psycho-somatic disorders 8 1 mood swings 8 1-82
-
psychotherapy see Phases; spontaneous 89, 128, 135
Setting; Treatment See also Treatment
psychotic children. patterns of regression to secondary autism
bchaviour 78-8 1 (R.S.A.) 84-85
psychotic depression autistic barrier 106-107
chmctcristic quality 23 bodily co-ordination &
encapsulation 50 scattering 12&12 1
John 4-3 1 comparison with A.P.A. and
Paul 168 E.S.A. 85-88
as precipitating factor in complication of cases 122
pathological autism differential features (Chart
69 11) 96-101
related to development 179 envy 122
Winnicott on 3.4 physical development of
Psychoric Stares (H. children 117
Rosenfeld) 138 precipitating factors (Chart
I) 92-93 .
R.S.A. -see Regression to Ralph 139-144
secondary autism regression as defence 92
rage - see Panic. terror and regression of development
rage %
Ralph 'too-open' feature of
autistic barrier 106 children 144
childhood schizophrenia treatment prospects 119-123
125,139-144 types distinguished 88-89
Ralph regression to secondary autism
clinical material 140-142, (Type 1) 88-89
143-144 lack of inner life 166-167
early history 139-140 Paul 16.3-168
INDEX
Toby 154-156 secondary autism;
regression to secondary autism Regression to
Crype 2) 88-89 secondary autism
Susan 119-121 seductive nurturing 74.84
Ralph 139-144 self-sufficiency 59
retention of faeces 66.79
'reverie' (Bion) 25.55.56, 108 sensory satisfaction, in therapy
*Rimland, B. 122-123
differential diagnosis 85. separateness
124,137 apprehension of 25-26
on: high intelligence factor factors precipitating shock
128. 129 75-77
mothers of autistic trauma of 4849.55.75,
children 13 1-132 77-78.105
parents' relations with setting, in psychotherapy 145-
psychotherapists 150 152
sensations and memory interpretations 1 4 6 149
172 supportive working
tantrums 113 conditions 15 1-152
twin evidence 133- 134 treatment setting 145-146
Robertson, J. 49 work with parents 149-151
Rodrigues, E. 170 -
sexuality see Bisexuality;
*Rosenfeld, H. 138 Male factor
*Rubinfine, D. L. 24,48,81, shadow. fear of 170
134 Shevrin, H. and Toussieng. P.
*Rutter. M. 103 70
The Shrimp and the Anemone
Sampson, Margaret 53 (L. P. Hartley) 48
saprophytic relationship 155 Sixth International Congress of
Sarah 66-67, 159-160.167 Psychotherapy 8.24
schizophrenia 85 skin 53-54.56
See also Childhood skin troubles 8 1
schizophrenia sleeping difficulties 8 1, 16 1
screaming 47, 127, 168 speech
See also John autistic types compared 87-
'scribble' talk 72. 87 88
*Sechahaye, Mme. 12 1 disorders 8 1
second skin phenomena 52-54 spinning 78, 155
See also Skin *Spitz. R.
secondary autistic processes film, Grief 70
32-50.75 on: dialogue between
See also Encapsulated mother and infant 86
*Spitz. R. (continued) See also Panic, terror and
on: infantile sensations rage
56.57 'telepathic' communication
institution infants 108 148-149
Isakower phenomenon tenderness 169
51 terror - see Panic. terror and
'primal cavity' 57, 112 rage
spontaneous recoveries 89. Tessa 52-53.54
128. 135 therapy - see Phases; Setting;
*Stem, M. M. 5 1 Treatment
*Stroh, G. 95 *Tischler, S. 24.81, 133
survival 113-1 14 Toby 154-156.161-162
Susan (normal infant observed) Tom 72-73
60-62 tongue 66.79.1 12-9
Susan (R.S.A.(2) child) 119- toys 157-158.171
121 trance dancing 78
symbiotic love object (Mahler) transitional object 62-64.65
8,20,87 trauma of separation 4849.
symbol formation 153, 166 55.75.77-78, 105
syndromes, specific 124-138 treatment of psychotic children
differential features (Chart 145-152
111) 136-138 'acting out' 123
See also Childhood author's method of
schizophrenia; Enrly psychotherapy 145
infantile autism autistic bmier, removal
systems of pathological autism from dilemma 107
69-101 classification as basis 3.
Abnormal primary autism 102-123
69-75 frustration as part of process
Encapsulated secondiuy 168-169
autism 75-84 inappropriatenessof sensory
Regression to secondary satisfaction 122-123
autism 84-85 interpretations 146-149
com pnrison of systems intuitions of therapist 148
85-88 prospects
differential features 96- A.P.A. 108-1 10
101 E.S.A. 11&119
tribulation by R.S.A. 119-123
precipitating factors setting 7.30, 145-146
92-95 supportive working
talent, high endowment 76 conditions 151-152
tantrums 23.47, 113, 127 work with parents 149-151
INDEX
trust. in therapy 173 false self 54, 122
*Tustin, F. on anorexia 'good enough' mothering
nervosa 174 75
Tustin, Prof. A. - illusion of continuity 25
Acknowledgements mother & baby freedom
twins, autistic 133-134 26
types of autism mother & baby
factors. precipitating (Chart interchange 20
I) 92-95 oil as healing medium
features. differential (Chart 173
11) 96-101 'pre-ruth' 113
See also Systems; primary holding situation
Syndromes 55
privation 7 1
verbal difficulties. non-verbal psychotic depression 3.4.
material 22. 33.47, 8
78, 149 'reacting too soon' 49
vestigial autism, in normal transitional experiences
individuals 83-84. 179 93
transitional object 62
waiting treatment holding
unbearable tension of 45.59 situation 7
use of transitional objects words
65 echolnlia and non-use of 64
*Wills, D. M. 73 experienced by John 22
*Wing, J. K. 125 to express horror 58
*Winnicott. D. W. 87 understanding of. by
ondoubledependence87 psychotic children
falling infinitely 5 1.70 146147

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AUTISM

This edition reprinted in 1995

Copyright 63 1972 by Frculces Tustin

All rights resewed. No part of this publication may be reproduced.

The rights of Frances Tustin to be identified as author of this work

Brltlsh Llbrary Cataloguing in Pubilcatlon Data

Printed in Oreat Britain by BPC Whcatons Ltd. Exeter

The responsibility for the views and insights described in

FOREWORD by Victoria Hamilton xi

Four 'Grit' and 'Second Skin' Phenomena

Five Autistic Processes: Further Discussion

Seven Systems of Pathological Autism

Autism and Childhood Psychosis was first published in

Normal Primary Autism

Autism and Contemporary Infancy Tlteory

THEaim of this chapter is to describe in detail, with the

Friday, January zoth, 1952 (Session 9)

Friday, Febrwry gth, 1952 (Session 23)

Monday, Noonnb~26th (Session 130)

Now that the infantile transference was well established and

Friday, April 5thJ1953 (Session 194)

Tuesday, January o&h, 1954 (Session 360)

For two sessions after this he was afraid of certain objects in

Treatment came to an end when John was aged 6: 5. This

John's Ex@rience of Gricf

The 'Black Hole'

AUTISTIC PROCESSES IN ACTION

I Nthe previous chapter clinical material was presented to

'GRIT' AND 'SECOND SKIN'

2 :SimilarMaterial to David's 'Suit of Amour'

Tessa aged ten years is a pupil at a day school for

NORMAL PRIMARY AUTISM

In the full account of the observation it is striking how

As Bowlby (1969)has emphasized, infants need other things

2. Partial LaGk of Essential Nurturing

As is to be expected, the sensory impediment of deafness is

Encap&d Secondcrry Autism (E.S.A.)

Freud rightly says that there is something about anxiety

Normal Abnormal Encapsulated Regressive

Normal Abnormal Encapsulated Regressive

Encapsulated Secondary A u h (E.S.A.)

Peter. A puzzling little boy. Recited many nursery

The E.S.A. children have had to face traumatic 'goneness'

In a state of secondary autism, the patient seems to feel that

The prognosis for R.S.A. children seems to depend upon

He also says that they are children of an 'intensely jealous

The Mothers of Autistic Children

The hypothesis concerning the possible etiology of Ewlg

A SETTING FOR PSYCHOTHERAPY

Interpretations have another value. Psychotic children keep

Work with Par&

One day, after going through the usual wrapping-up pro-

At the time of writing, as the result of further clinical

In the light of the above comments, Pal's session will now

By Lilian Rubin, M.A.

Note: An asterisk denotes a mention in the list of References.

abnormal primary autism anxiety -see Fright, fear and

R.S.A. (q.v.) 85-88

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(Maresfield Library) Frances Tustin - Autism & Childhood Psychosis-Karnac Books (1995)

(Maresfield Library) Frances Tustin - Autism & Childhood Psychosis-Karnac Books (1995)